On request of an inspector, the owner, part owner, or caretaker, or a person accompanying and connected with a shipment, of animals that are being moved in this state or have been moved in this state within 60 days preceding the request, shall make a written statement of:
(1) the name of the owner or the person controlling the land from which the shipment originated and the county in which that land is located;
(2) the county and the particular place in that county to which the shipment is or was destined;
(3) the name and address of the person from whom the animals were obtained, if the animals were obtained in the 30 days preceding the request, or, if the animals were not obtained during the 30 days preceding the request, a statement of that fact; and
(4) the territory through which the shipment passed since leaving the point of origin and through which the shipment is intended to pass before reaching the point of destination.