The authorized person shall attach to the will a certificate to be signed by the authorized person establishing that the requirements of the Uniform International Wills Act 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 must be substantially in the following form:

1. 1. ___________________ (name, address, date and place of birth)

2. 2. ___________________ (name, address, date and place of birth) has declared that the attached document is the will of the testator and that the testator knows the contents thereof.

   I furthermore certify that:

3. 1. In my presence and in that of the witnesses

   1. a. the testator has signed the will or has acknowledged the signature of the testator previously affixed.

   2. b. following a declaration of the testator stating that the testator was unable to sign the will for the following reason ______________________, I have mentioned this declaration on the will

      *and the signature has been affixed by ______________________ (name and address);

4. 2. The witnesses and I have signed the will;
5. 3. Each page of the will has been signed by _________________ and numbered;
6. 4. I have satisfied myself as to the identity of the testator and of the witnesses as designated above;
7. 5. The witnesses met the conditions requisite to act as such according to the law under which I am acting;

8. 6. The testator has requested me to include the following statement concerning the safekeeping of the will of the testator:

   Place of Execution ______________________________________

   Date ____________________________________________________

   Signature _______________________________________________

   and, if necessary, SEAL

   *to be completed if appropriate

CERTIFICATE

I, _______________________ (name, address and capacity), a person authorized to act in connection with international wills

Certify that on _________ (date) at ________________ (place)

(testator) _______________________ (name, address, date and place of birth) in my presence and in that of witnesses

Laws 2010, SB 889, c. 383, § 6, eff. November 1, 2010.