The certificate required by Rule 1042.3(a) shall be substantially in the following form:

(Caption)

Certificate of Merit as to

____________

(Name of Defendant)

I,

____________

, certify that:

(Attorney or Party)

[] an appropriate licensed professional has supplied a written statement to the undersigned that there is a basis to conclude that the care, skill or knowledge exercised or exhibited by this defendant in the treatment, practice or work that is the subject of the complaint, fell outside acceptable professional standards and that such conduct was a cause in bringing about the harm;

AND/OR

[] the claim that this defendant deviated from an acceptable professional standard is based solely on allegations that other licensed professionals for whom this defendant is responsible deviated from an acceptable professional standard and an appropriate licensed professional has supplied a written statement to the undersigned that there is a basis to conclude that the care, skill or knowledge exercised or exhibited by the other licensed professionals in the treatment, practice or work that is the subject of the complaint, fell outside acceptable professional standards and that such conduct was a cause in bringing about the harm;

OR

[] expert testimony of an appropriate licensed professional is unnecessary for prosecution of the claim against this defendant.

Date:

____________

…

____________

(Attorney or Party)