Cal. 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, ifnecessary, SEAL | |
| __________*to be completed if appropriate |