A. A certification order must contain:

(1)     the question of law to be answered;

(2)     the facts relevant to the question, showing fully the nature of the controversy out of which the question arose;

(3)     a statement acknowledging that the supreme court of this state, acting as the receiving court, may reformulate the question; and

(4)     the names and addresses of counsel of record and parties appearing without counsel.

B. If the parties cannot agree upon a statement of facts, the certifying court shall determine the relevant facts and state them as part of its certification order.