When the execution of an instrument is proved by proof of the signature of a subscribing witness as provided by N.C. Gen. Stat. § 47-12.1, the certificate required by N.C. Gen. Stat. § 47-13.1 shall be in substantially the following form:

STATE OF________________________________________

                                          (Name of state)

_________________________________________ COUNTY

I, ____________________________, a ______________________________________

               (Name of officer taking proof)                    (Official title of? officer taking proof)

of ___________________ COUNTY, _______________________________, certify that

                                                                                             (Name of state)

____________________________________ personally appeared before me this day, and

            (Name of person familiar with

         handwriting of subscribing witness)

being duly sworn, stated that he knows the handwriting of ________________________,

                                                                                                      (Name of subscribing witness)

and that the signature of __________________________ as a subscribing witness to the

                                             (Name of subscribing witness)

foregoing instrument is the signature of _______________________________________

                                                                                       (Name of subscribing witness)

WITNESS my hand and official seal, this the ____ day of ______________, ________

                                                                                                               (Month)                 (Year)    

                                                         _________________________________________________

                                                               (Signature of officer taking proof)

                                                         _________________________________________________

                                                               (Official title of officer taking proof)

My commission expires _________________________________________________

                                                               (Date of expiration of officer’s commission)

?(1951, c. 379, s. 3; 1999-456, s. 59.)