Sec. 6. If the form used by an applicant to decline to register to vote is on a separate form from the voter registration application, the declination form must contain the following:
(1) A statement reading "If you decline to register to vote, this is confidential, and can only be used for voter registration purposes.".
(2) A statement reading "If you decide to register to vote, information about the office at which you register is confidential, and can only be used for voter registration purposes.".
(3) A line for the signature of the person who declines to register to vote.
(4) A line for the date that the person declined to register to vote.