An unsworn declaration under this chapter must be in substantially the following form:
I declare under penalty of perjury under the law of the Commonwealth of Pennsylvania that the foregoing is true and correct, and that I am physically located outside the geographic boundaries of the United States, Puerto Rico, the Virgin Islands and any territory or insular possession subject to the jurisdiction of the United States.
Executed on the........day of........,........,
at............................................,
(date)........(month)...........(year).........
(city or other location, and state)............
...............................................
(country)..................................
(printed name).............................
(signature)................................