The certificate authenticating a printed electronic record under § 18-1-11.5 must be substantially in the following form:
I, ______________, a notary public, certify that the attached document is an accurate copy of the original electronic record upon which my electronic signature and official seal are inscribed, and that the electronic record was printed by me or under my supervision.
I hereunto set my hand and official seal.
_______________________________
_______________________________
Title of officer.