The certificate drawn up by the authorized person shall be in the following form or in a substantially similar form:

CERTIFICATE

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

*—the signature has been affixed by ............ (name, 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

13.Date

14.Signature and, if necessary, Seal

  *To be completed if appropriate.