A farm owner or operator who petitions the Department as provided under Regulation .02 of this chapter shall use a departmental form that contains: The name and address of the farm owner or operator; The farm's location; The farm's total acreage; A description of the farm's operation; The number of nontidal wetland acres requiring mitigation; A copy of proposed mitigation alternatives; The estimated cost or costs of the mitigation proposal or proposals, verified by the local soil conservation district; A statement showing how mitigation will jeopardize the continued operation of the farm; A financial statement: Showing the owner or operator's complete assets and liabilities for the most current 2 consecutive years, and Signed by the owner or operator under the penalty of perjury that the information contained in the financial statement is true and correct; and Any additional information supporting the claim of economic hardship, including, for example, information from mortgagees, other lien holds, creditors, attorneys, the Internal Revenue Service, or any other third party interest who is qualified to address the economic condition of the owner or operator.