(1) The authorized person shall attach to the will a certificate to be signed by him establishing that the requirements of this part 10 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.

(2) The certificate shall be substantially in the following form:

CERTIFICATE

1.I, --------------- (name, address, and capacity), a person authorized to act in connection with international wills,-- 2.certify that on ------ (date) at --

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-------- (place)-- 3.(testator) -----------------------------------------------

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-------------(name, address, and date and place of birth) in my presence and that of the witnesses-- 4.(a) ------------- (name, address, and date and place of birth)--(b) ------------- (name, address, and date and place of birth) has declared that the attached document is his will and that he knows the contents thereof.--*(c) -------------- (social security number or any other individual-identifying number established by law)-- 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) (to be completed if testator unable to sign)-- 7.(b) the witnesses and I have signed the will;-- 8.*(c) each page of the will has been signed by --------------- and numbered (to be completed if testator unable to sign);-- 9.(d) I have satisfied myself as to the identity of the testator and of the witnesses as designated above;-

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10.(e) the witnesses met the conditions requisite to act as such according to the law under which I am acting;--*(f) the intended place of deposit of safekeeping of the instrument pending the death of the testator is -----------------.-- 11.*(g) the testator has requested me to include the following statement concerning the safekeeping of his will:

12.PLACE OF EXECUTION

13.DATE

14.SIGNATURE

* to be completed if appropriate