California Code, Probate Code - PROB § 6384

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

__________