A gives to B $_____ conditioned on her surviving him _________ months subsequent to his death, which payment shall be made by the executors or administrators of A six months after the decease of A, and shall bear interest at the rate of _____% per annum from the date of the decease of A, it being the intention of the parties that should B predecease A or not survive him for a period of six months that no right or interest in and to the estate of A shall accrue under this agreement to B, her heirs, executors, administrators, or assigns.

B accepts $_____ to be paid her as conditioned upon and provided for in the immediately preceding paragraph _________ of this agreement, in full satisfaction of any and all claim, demand, right, title, interest, or dower of, in and to the estate, real, personal, or mixed, which A is now or may later become or die seized or entitled to; and B is forever barred and estopped from claiming, demanding, or setting up any and all right, title, interest, dower, or share of, in and to the estate, real, personal, and mixed, which A is now or may later become or die seized of or entitled to, excepting, however, $_____ provided in this agreement to be paid her and to any additional provision or sum that may be provided for her by A in his last will.