I agree the sample seems a little disconnected from the requirements, but the regulation also states it must be substantially similar. Because of this I recommend using the sample format.
1026.20(d)(3): 3) Format. (i) Except for the disclosures required by paragraph (d)(2)(i) of this section, the disclosures required by this paragraph (d) shall be provided in the form of a table and in the same order as, and with headings and format substantially similar to, forms H-4(D)(3) and (4) in appendix H to this part;