I, ____________ (name, address, and capacity), a person authorized to act in connection with international wills, certify that on __________ (date), at ___________ (place), testator________ (testator's name, address, and date and place of birth),  in my presence and that of the witnesses ____________ (name, address, and place and date of birth of first witness) and ____________ (name, address, and place and date of  birth of second witness) has declared that the attached document is his or her will and that he or she knows its contents.

I further certify that:

   (1) In my presence and in that of the witnesses:

     (A) the testator has signed the will or has acknowledged his or her signature previously affixed; or

     (B) (If Necessary) following a declaration of the testator stating that he or she was unable to sign his or her will for the following reason ________, I have mentioned this declaration in the will and the signature has been affixed by _________________ (name and address).

   (2) The witnesses and I have signed the will.

   (3) Each page of the will has been signed by ________ and numbered.

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

   (5) The witnesses met the conditions requisite to act as such according to the  law under which I am acting.

   (6) (If Necessary) The testator has requested me to include the following statement concerning the safekeeping of his or her will: ________.