Alaska Stat. § 13.12.915

The authorized person shall attach to the international will a certificate to be signed by the authorized person establishing that the requirements of AS 13.12.912 — 13.12.921 for valid execution of an international will have been complied with. 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 wills2. certify that on __________ (date) at __________________________________ (place)3. (testator) _____________________________________ (name, address, date, and place of birth) in my presence and that of the witnesses4. (a) _____________________________________ (name, address, date, and place of birth)(b) _____________________________________ (name, address, date, and place of birth) has declared that the attached document is the testator's will and that the testator knows the contents of the will;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 the testator's signature previously affixed.* (2) following a declaration of the testator stating that the testator was unable to sign the testator's 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 witnesses 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 the testator's will:______________________________________12. PLACE OF EXECUTION13. DATE14. SIGNATURE and, if necessary, SEAL* to be completed if appropriate.