C.R.S. § 15-11-1006: Certificate that requirements for an international will have been met.

(1) The authorized person shall attach to the will a certificate to be signed by him establishing that the requirements of this part 10 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.

(2) The certificate shall be substantially in the following form:

CERTIFICATE

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, and date and place of birth) in my presence and that of the witnesses

4. (a) _____________ (name, address, and date and place of birth) (b) _____________ (name, address, and date and place of birth) has declared that the attached document is his will and that he knows the contents thereof. *(c) ______________ (social security number or any other individual-identifying number established by law)

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) (to be completed if testator unable to sign)

7. (b) the witnesses and I have signed the will;

8. *(c) each page of the will has been signed by _______________ and numbered (to be completed if testator unable to sign);

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; *(f) the intended place of deposit of safekeeping of the instrument pending the death of the testator is _________________.

11. *(g) the testator has requested me to include the following statement concerning the safekeeping of his will:

12. PLACE OF EXECUTION

13. DATE

14. SIGNATURE

* to be completed if appropriate