If the custodian refuses a requested correction or amendment of a personal record, the person in interest may file with the head of the agency that has authority over the personal record a concise statement of the reasons for disagreeing with the agency's refusal to make the correction or amendment. The person in interest filing a statement under §A of this regulation shall: File the statement in writing; Submit the statement on one side of 81/2 x 11 inches paper; and Limit the statement to a maximum of five pages. If a custodian discloses, to a third party, information from a personal record related to a statement filed under §A of this regulation, the custodian shall provide the third party a copy of that statement.