(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 receiving court may reformulate the question; and
(4) The names and addresses of counsel of record and unrepresented parties.
(b) If the parties cannot agree upon a statement of facts, then the certifying court shall determine the relevant facts and shall state them as a part of its certification order.