§ 276. Filing of statement. A person who uses in this state a name, mark or device to indicate ownership of vessels, receptacles or utensils may file in the office of the secretary of state, on a form to be furnished or approved by him, a statement subscribed by such person and affirmed by him as true, under the penalties of perjury setting forth, but not limited to, the following information:

(a) The name and business address of the person filing the statement; and, if a corporation, the state of incorporation.

(b) The nature of the business of the person filing.

(c) The type of vessels, receptacles and utensils in connection with which the name, mark or device is used. The statement shall include or be accompanied by a copy, specimen, facsimile or counterpart of such name, mark or device in quadruplicate, together with a filing fee of fifty dollars.