Indiana Code Title 29. Probate § 29-1-21-13

(1) Beginning on (insert date of first possession of the electronic will by the signatory of this affidavit) and continuing to the date and time of this affidavit, the undersigned person has had possession of (circle all that apply):

of (insert name of testator), which was electronically executed on (insert date of electronic signing and attestation or insert reference to time and date stamp).

(2) (Insert client number, customer number, document number, or other unique identifier if any) is the unique identifier that the undersigned person assigned to this electronic will in the undersigned person's records.

(3) The undersigned person believes that the testator (circle one (1) of the following):

(4) The undersigned person is (circle all of the following that apply):

(5) If the undersigned person is transferring or submitting the electronic record for the electronic will, it is in the following format (insert description of the format).

(6) If the undersigned person is transferring or submitting the electronic record for the electronic will, the undersigned person affirms, under penalty of perjury, that the electronic record has been in the undersigned person's possession or control for the period of time stated in paragraph (1) and that during the specified period of time the electronic record showed no indication of unauthorized alteration or tampering.

(7) The undersigned person affirms, under penalty of perjury, that (circle one (1) of the following):

(8) The undersigned person is (circle one (1) if applicable):

____________________________________________________________

(insert date and time of custodian's or other person's signature)

____________________________________________________________

(insert name and signature of custodian or other person signing)

____________________________________________________________

(insert job title or position of signatory if signatory is not an individual).”.