Sec. 4. A maternity home operator that seeks to claim a tax credit under IC 6-3.1-14 for operating a maternity home that is registered under this chapter shall file with the state department a form provided by the state department certifying the following information:
(1) The tax credit the maternity home operator desires to claim for the taxable year.
(2) Information on each pregnant woman claimed, including the following:
(A) Name.
(B) Last known address.
(C) Dates resided with maternity home operator.
(D) Current status of pregnancy.
(E) Date or expected date of delivery.