An authority may require any request for private activity bond financing when submitted to the authority to be accompanied by a statement in the following form, but the absence of any such form shall not affect the validity of a private activity bond: ________________ Date _________________ (Name of Applicant) _________________ (Facility) Signature ____________________ Authority Chairman _____________________ Name of Authority If one or more of the above questions do not apply to the facility indicate by writing N/A (not applicable) on the appropriate line. The provisions of this section shall not apply to bonds, notes or other obligations issued pursuant to hearings held and governmental approvals obtained prior to the effective date of this act in compliance with federal law or regulation.