An unsworn declaration under this chapter must be in substantially the following form:
I declare under penalty of perjury under the law of the Commonwealth of Pennsylvania that the foregoing is true and correct.
Signed on the........day of........,........,
at............................................,
(date)........(month)...........(year).........
(county or other location, and state)............
...............................................
(country)..................................
(printed name).............................
(signature)................................