Indiana Code Title 24. Trade Regulation § 24-4.6-5-5

(1) state the total pump price of the motor fuel pumped into the vehicle owner's vehicle and the amount of the service charge;

(2) state how the vehicle owner is to pay the liability;

(3) include a copy of this chapter and IC 34-24-3;

(4) state that, subject to section 6(b) of this chapter, the vehicle owner is subject to liability for an amount equal to triple the total pump price of the motor fuel received plus other damages under IC 34-24-3-1 if the liability is not paid within thirty (30) days;  and

(5) include a signed statement by the retailer or the employee of the retailer who reported the incident in which motor fuel was pumped into the vehicle owner's vehicle and proper payment was not made, setting forth: