(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 ___________ (place) 3. (testator) ___________________________________________________________ (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; 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
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