Any customer electing to opt out under section 4928.6611 of the Revised Code shall do so by providing a verified written notice of intent to opt out to the electric distribution utility from which it receives service and submitting a complete copy of the opt-out notice to the secretary of the public utilities commission. The notice provided to the utility shall include all of the following:

1. (A) A statement indicating that the customer has elected to opt out;
2. (B) The effective date of the election to opt out;
3. (C) The account number for each customer account to which the opt out shall apply;
4. (D) The physical location of the customer's load center;
5. (E) The date upon which the customer established, or plans to establish a process and implement, cost-effective measures to improve its energy efficiency savings and peak demand reductions.