The authorized individual shall attach to the will a certificate signed by the authorized individual establishing that the will complies with the requirements of this part for valid execution of an international will. The authorized individual shall keep a copy of the certificate and deliver another to the testator. The certificate must be in substantially the following form, except the provisions of the form that are optional provisions need only be included if the circumstances of the will render them applicable:

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 _______ at ______________________________
(Date)	(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 (or her) will andthat he (or she) 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 (or her) signature previously affixed. * following a declaration of the testator stating that he (or she) (2) was unable to sign his (or her) 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 have 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 (or her) will:
12. PLACE OF EXECUTION
13. DATE
14. SIGNATURE and, if necessary, SEAL
* to be completed if appropriate.