(a) A certificate of dissolution, entitled "Certificate of dissolution of ......... (name of corporation) under section 1003 of the Business Corporation Law", shall be signed and delivered to the department of state. It shall set forth:

(1) The name of the corporation and, if its name has been changed, the name under which it was formed.

(2) The date its certificate of incorporation was filed by the department of state.

(3) The name and address of each of its officers and directors.

(4) That the corporation elects to dissolve.

(5) The manner in which the dissolution was authorized.