Cal. PROB § 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