14 V.S.A. § 135

(a) The authorized person shall sign and attach to the will a certificate establishing that there has been compliance with the requirements of this chapter for valid execution of an international will. The authorized person shall keep a copy of the certificate and deliver another copy to the testator.

(b) The certificate required by this section shall be in substantially the following form:

CERTIFICATE OF AUTHORIZED PERSON

I, ________ (name, address, and capacity), a person authorized to act in connection with international wills, certify that on ________ (date), at ________ (place), testator________ (testator's name, address, and date and place of birth), in my presence and that of the witnesses ________ (name, address, and place and date of birth of first witness) and ________ (name, address, and place and date of birth of second witness) has declared that the attached document is his or her will and that he or she knows its contents.

I further certify that:

(1) In my presence and in that of the witnesses:

(A) the testator has signed the will or has acknowledged his or her signature previously affixed; or

(B) (If Necessary) following a declaration of the testator stating that he or she was unable to sign his or her will for the following reason ________ , I have mentioned this declaration in the will and the signature has been affixed by ________ (name and address).

(2) The witnesses and I have signed the will.

(3) Each page of the will has been signed by ________ and numbered.

(4) I have satisfied myself as to the identity of the testator and of the witnesses as designated above.

(5) The witnesses met the conditions requisite to act as such according to the law under which I am acting.

(6) (If Necessary) The testator has requested me to include the following statement concerning the safekeeping of his or her will: ________ .

_________________________________________

(SIGNATURE, DATE AND PLACE OF EXECUTION)