1. The name and residential address of the remotely located individual.
2. The name and residential or business address of the notary public.
3. The address within the state where the remotely located individual was physically located at the time that the estate planning document was signed by the remotely located individual or another individual on behalf of the remotely located individual.
4. The address within the state where the notary public was physically located at the time the notary public witnessed the remotely located individual’s signing of the estate planning document.
5. A statement that the remotely located individual and notary public were known to each other and the supervising attorney or a description of the form of identification used to confirm the identity of the remotely located individual.
6. The identity of anyone else present in the same physical location as the remotely located individual during the signing.
7. Confirmation that the remotely located individual declared that the remotely located individual is 18 years of age or older, that the document is the remotely located individual’s estate planning document, and that the document was being executed as the remotely located individual’s voluntary act.
8. Confirmation that the notary public and the supervising attorney were able to see the remotely located individual, or an individual 18 years of age or older at the express direction and in the physical presence of the remotely located individual, sign, and that the remotely located individual appeared to be 18 years of age or older and acting voluntarily.
9. A description of the audiovisual technology used for the signing process.
10. If the estate planning document was not signed in counterpart, a description of the method used to forward the estate planning document to the notary public and to the supervising attorney upon completion of the signing process.
11. If the estate planning document was signed in counterpart, a description of the method used to forward each counterpart to the supervising attorney and, if applicable, how and when the supervising attorney physically compiled the signed paper counterparts into a single document.
12. The name, state bar number, and business or residential address of the supervising attorney.
13. Any other information that the supervising attorney considers to be material with respect to the remotely located individual’s capacity to sign a valid estate planning document, the remotely located individual’s and notary public’s compliance with this section, or any other information that the supervising attorney deems relevant to the signing of the estate planning document.
(4) An affidavit of compliance completed and attached to the estate planning document pursuant to sub. (3) (k) shall serve as conclusive evidence that the estate planning document was executed in compliance with this section.
(5) An affidavit of compliance shall be in substantially the following form:
AFFIDAVIT OF COMPLIANCE
State of ....
County of ....
The undersigned, being first duly sworn under oath, states as follows:
This Affidavit of Compliance is executed pursuant to Wis. Stat. § 140.147 to document the signing of the [name of estate planning document] of [name of remotely located individual] via remote appearance by 2-way, real-time audiovisual communication technology on [date].
1. The name and residential address of the remotely located individual is ....
2. The name and [residential or business] address of the notary public is ....
3. The address within the state of Wisconsin where the remotely located individual was physically located at the time the remotely located individual signed the estate planning document is ....
4. The address within the state of Wisconsin where the notary public was physically located at the time the notary public witnessed the remotely located individual’s signing of the estate planning document is ....
5. The remotely located individual and notary public were known to each other and to the supervising attorney. - OR - The remotely located individual and notary public were not known to each other and to the supervising attorney. The remotely located individual produced the following form of photo identification to confirm his or her identity:
....
6. The following persons were in the same physical location as the remotely located individual during the signing:
....
7. The remotely located individual declared that the remotely located individual is 18 years of age or older, that the document is the remotely located individual’s [name of estate planning document], and that the document was being executed as the remotely located individual’s voluntary act.