Any certificate for proof of execution taken within this state may be in the following
form, although the use of other, substantially similar forms is not precluded:
State of California } ss.
County of _________
On __________ (date), before me, the undersigned, a notary public for the state, personally
appeared _________________ (subscribing witness’s name), personally known to me (or
proved to me on the oath of _________________ (credible witness’s name), who is personally
known to me) to be the person whose name is subscribed to the within instrument, as a witness
thereto, who, being by me duly sworn, deposed and said that he/she was present and saw
_________________ (name(s) of principal(s)), the same person(s) described in and whose
name(s) is/are subscribed to the within and annexed instrument in his/her/their authorized
capacity(ies) as (a) party (ies) thereto, execute the same, and that said affiant subscribed his/her
name to the within instrument as a witness at the request of _________________ (name(s) of
WITNESS my hand and official seal.
Signature ______________________________________ (Seal)