(b) This notice must contain:
(1) The date and amount of the check, draft or order;
(2) The name of the payee or holder;
(3) The date by which the individual must contact the designated representative of the worthless check restitution program;
(4) A demand for full restitution of the face amount of the check, draft or order and any fees reflected in the complaint or warrant as having been imposed on the payee or holder by the payee's or holder's bank or financial institution; and
(5) A statement that failure to pay restitution and fees may result in criminal prosecution.