The ballot for an election under this subchapter must be printed to permit voting for or against the proposition: “The dissolution of the Ballinger Memorial Hospital District and the creation of the Runnels County Hospital District, providing for the imposition of an ad valorem tax at a rate not to exceed ____ cents (insert any rate not to exceed 75 cents) on each $100 valuation of taxable property in Runnels County, and providing for the transfer to and assumption by the Runnels County Hospital District of all outstanding bonds and other obligations issued for hospital purposes by the Ballinger Memorial Hospital District, Runnels County, and any part of a municipality located in Runnels County, and the transfer of the existing Ballinger Memorial Hospital District’s assets to the Runnels County Hospital District.”