(a) An authorized person shall attach to the will a certificate to be signed by the authorized person establishing that the requirements for valid execution of an international will have been met.

(b) The authorized person shall keep a copy of the certificate and deliver a copy to the testator.

(c) A certificate under this section shall be substantially in the following form:

“CERTIFICATE

(Convention of October 26, 1973)

I, __________________ (name, address, and capacity), a person authorized to act in connection with international wills, certify that on ________________________ (date) at__________________(place)___________________(testator)____________________(name, address, and date and place of birth) in my presence and that of the witnesses: _____________________ (name, address, and date and place of birth); and _____________________ (name, address, and date and place of birth) has declared that the attached document is the testator’s will and that the testator knows the contents of the will.

I further certify that in my presence and in the presence 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 ____________________, I have noted this declaration on the will and the signature has been affixed by _____________ (name and address);

(3) the witnesses and I have signed the will;

(4) each page of the will has been signed by _______________________ (name and address) and numbered;

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

(6) the witnesses met the conditions requisite to act as such according to the law under which I am acting; and

(7) the testator has requested me to include the following statement concerning the safekeeping of the testator’s will: ____________________________________________________________________.

PLACE OF EXECUTION _____________________

DATE ________________________________________

SIGNATURE _________________________________ and, if necessary, SEAL”.