The authorized person shall attach to the will a certificate to be signed by the authorized person establishing that the requirements of the Uniform Wills Recognition Act (1977) for valid execution of an international will have been complied with. The authorized person shall keep a copy of the certificate and deliver another to the testator. The certificate shall be substantially in the following form:

CERTIFICATE

(Convention of October 26, 1973)

1. I, .................... (name, address, and capacity), a person authorized to act in connection with international wills

2. Certify that on .............. (date) at ................... (place)

3. (testator) ......................................... (name, address, date, and place of birth) in my presence and that of the witnesses

4. (a) .............................. (name, address, date, and place of birth)

(b) .............................. (name, address, date, and place of birth)

has declared that the attached document is the testator's will and that the testator knows the contents thereof.

5. I furthermore certify that:

6. (a) in my presence and in that of the witnesses

(1) the testator has signed the will or has acknowledged the testator's signature previously affixed.

*(2) following a declaration of the testator stating that the testator was unable to sign the testator's will for the following reason ........................................., and I have mentioned this declaration on the will

*and the signature has been affixed by ...................................... (name, address)

7. (b) the witnesses and I have signed the will;

8. *(c) each page of the will has been signed by ........................ and numbered;

9. (d) I have satisfied myself as to the identity of the testator and of the witnesses as designated above;

10. (e) the witnesses met the conditions requisite to act as such according to the law under which I am acting;

11. *(f) the testator has requested me to include the following statement concerning the safekeeping of the testator's will:

.................................................................

12. PLACE ................................................

13. DATE ................................................

14. SIGNATURE ................................................

and, if necessary, SEAL

*to be completed if appropriate