Michigan § 700.2955 - Certificate.

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 _______ at ______________________________

(Date)

(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 (or her) will and

that he (or she) 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 (or her) signature previously affixed. * following a declaration of the testator stating that he (or she) (2) was unable to sign his (or her) 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 have 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 (or her) will:

12. PLACE OF EXECUTION

13. DATE

14. SIGNATURE and, if necessary, SEAL

* to be completed if appropriate.