(1) a declaration by the woman or the person who has agreed to give birth to the child in the context of the parental project, dated and signed by the woman or the person, containing(a) the name and address of the woman or the person;
(b) for each expense concerned,i. its nature;
ii. the amount incurred and, if less than the amount incurred, the amount requested for reimbursement;
iii. the date on which it was incurred; and
iv. a statement indicating that the amount requested has not been paid or reimbursed to them, in whole or in part, by any other source;
(c) in the case of transportation expenses incurred for the use of an automobile, except an automobile used by a transportation service that provides a receipt, the following additional information:i. the addresses of the points of departure and destination; and
ii. the number of kilometres travelled between those 2 points;
(d) a statement indicating that all the expenses have been incurred by reason of their contribution to the parental project;
(e) a statement indicating that all the information contained in the declaration is accurate and complete to the best of their knowledge;