Issuer / contact: __________________
Certificate reference: __________ Issue date: __________
Artwork title: _____________________________________
Artist / maker: ____________________________________
Date created: __________ Medium: __________________
Dimensions: __________ Edition / number: __________
Item photograph reference: _________________________
Basis for the issuer statement: ____________________
Provenance / supporting records: ___________________
Issuer name / role / signature: ____________________
The statement is only as reliable as the issuer and evidence.