Prob. Code, § 6384

The authorized person shall attach to the will a certificate to be signed by the authorized person establishing that the requirements of this chapter for valid execution of an international will have been fulfilled. 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 his will and that he 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 his signature previously affixed.

(2) following a declaration of the testator stating that he was unable to sign his will for the following reason ________________, I have mentioned this declaration on the will,* and the signature has been affixed by ______(name and 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 his will:* ______

12. PLACE OF EXECUTION

13. DATE

14. SIGNATURE and, if necessary, SEAL

__________ *to be completed if appropriate