The disclosure statement must state whether the provider is affiliated with a religious, charitable, or other nonprofit organization, and if so, the statement must:
(1) describe the extent of the affiliation;
(2) explain the extent to which the organization is responsible for the financial and contractual obligations of the provider; and
(3) cite any provision of the Internal Revenue Code of 1986 under which the provider or affiliate claims to be exempt from the payment of income tax.