§ 6384 — California Probate Code

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

(Enacted by Stats. 1990, Ch. 79.)