The certificate required by Rule 4009.22(a) as a prerequisite to the service of a subpoena shall be substantially in the following form:

1. (CAPTION) CERTIFICATE
   PREREQUISITE TO SERVICE OF A SUBPOENA
   PURSUANT TO RULE 4009.22

   As a prerequisite to service of a subpoena for documents and things pursuant to Rule 4009.22,

   certifies that (Plaintiff/Defendant)

2. (1) a notice of intent to serve the subpoena with a copy of the subpoena attached thereto was mailed or delivered to each party at least twenty days prior to the date on which the subpoena is sought to be served,
3. (2) a copy of the notice of intent, including the proposed subpoena, is attached to this certificate,
4. (3) no objection to the subpoena has been received, and

5. (4) the subpoena which will be served is identical to the subpoena which is attached to the notice of intent to serve the subpoena.

   Date:

   … Attorney for