(a) Statements of income and expenses and production submitted pursuant to this Title shall be made available to a person seeking to inspect same only after that person shall have completed and signed a form prescribed by ORPTS which shall include the following information:

1. (1) the name of the person seeking to inspect;
2. (2) specific reference to the statements sought to be inspected or copied sufficient to identify them to the custodian of the statements;
3. (3) a statement certifying that the inspection of the form is for purposes of administrative or judicial review of assessments;
4. (4) the administrative or judicial body before which the assessment is to be reviewed; and
5. (5) the date on which the producer whose information is the subject of the proposed disclosure was given written notice of such proposed disclosure.