The registrant shall submit a statement to the secretary of state that identifies the escrow agent, the style of the deposit account, the name and address of the financial institution, and any other information which will identify the escrow account into which the prepayments have been deposited. In addition, the statement must give authority to the secretary of state to direct inquiries to the financial institution regarding the escrow account. The statement shall be on a form prescribed by the secretary of state. The statement shall be signed and notarized by the registrant and signed by the escrow agent.