1. A customer may authorize disclosure of his financial records if he furnishes to the financial institution and to the government authority seeking to obtain such disclosure a signed and dated statement which:

(1) Authorizes such disclosure for such period as may be agreed upon;

(2) States that the customer may revoke such authorization at any time before the financial records are disclosed;

(3) Identifies the financial records which are authorized to be disclosed;

(4) Specifies the purpose and the government authority to which such records may be disclosed; and

(5) States the customer’s rights under sections 408.675 to 408.700.

2. Such authorization shall not be required as a condition of doing business with any financial institution.

3. The customer has the right to obtain a copy of the information which shall be disclosed to a government authority pursuant to sections 408.675 to 408.700, and the identity of the government authority to which such disclosure was made.