Upon the filing of an application as provided in section 12-2404, the justice of the peace or clerk of any superior court shall issue a notice directed to any party against whom any provisional remedy would operate substantially in the following form:

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"NOTICE

You are hereby notified that your (property) may be taken away from you by (party seeking provisional remedy), who says that you owe (such party) a debt of $(amount). (Party seeking provisional remedy), your creditor, wants to take your property so that (such party) can be sure you will pay if the court decides that you owe money to (party seeking provisional remedy). If you do not want to have your property taken away, you may ask for a hearing before a court. You may ask for the hearing anytime in the next ten days. The hearing will take place within five working days after you ask for it. You may ask for the hearing by checking the box at the bottom of this notice and filing it with the court or division of the court, at the following address: (address of court or division of the court). You must also send a copy to (party seeking provisional remedy) at (address), so that (such party) knows you want the hearing. At the hearing the court will decide whether the claim against you is probably valid and whether other legal requirements have been met. If you do not check the box requesting a date for a hearing and take this notice to the court within ten days, the court will automatically assume you do not want a hearing and you will lose your right to a hearing. Then (party seeking provisional remedy) may take your property with the court’s permission."