Cal. Prob. Code § 6384
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, if necessary, SEAL | |||
__________ *to be completed if appropriate | ||||
Ca. Prob. Code § 6384