A ground rent agreement made pursuant to the provisions of this chapter may be incorporated into the deed or other instrument of transfer in the following form: This deed is subject to annual ground rent or charge as follows:

1. Date of agreement: ______;

2. Parties: a. Obligor: ______; and b. Obligee: ______;

3. Ground rent and any future adjustments to it: ______;

4. When payable: ______;

5. Duration: ______;

6. Original value of land: ______; and

7. Redemption price, if agreed on: ______.