1.  Person seeking sterilization or for whom sterilization is sought.  Name, age and residence of the person seeking sterilization or for whom sterilization is sought;  

2.  Parent, guardian or spouse.  Names and residences of any parents, spouse or guardian of the person seeking sterilization or for whom sterilization is sought;  

3.  Basis of petition.  A statement of the factors, including any listed in section 7004, subsection 2, and mental condition, when appropriate, which necessitate a determination of the ability of the person seeking sterilization or for whom sterilization is sought to give informed consent for sterilization;  

4.  Reasons for sterilization.  A statement of the reasons for which sterilization is sought; and  

5.  Person initiating petition.  The name, address, position and statement of interest of the person initiating the petition or any person assisting with a self-initiated petition.