The certificate of acknowledgment of a document executed under § 18-1-11.1 shall be substantially in the following form:
State of South Dakota
County of _____ ss
On this _____ day of _____, in the year_____, before me, _____ (Notary's Name), the undersigned officer appeared _____ (Signer's Name) with a remote location of _____ (City/State), whom I have personal knowledge of because of my relationship as _____ and whom I positively identified as the person whose name is subscribed to the within instrument, appeared before me not in my physical presence but by means of video communication technology, and I observed his/her execution of the same for the purposes contained therein and confirm that I affix my seal to the same instrument so executed.