(b) The CBEC member shall report the following information on the approved form:

1. (1) The filing year;
2. (2) CBEC member name;
3. (3) CBEC member address;
4. (4) CBEC member city, state, zip;
5. (5) CBEC member county of residence;

6. (6) Either check a box stating that during the previous calendar year, the CBEC member has not had any sales referenced in Arkansas Code § 7-4-119, or fill in relevant sales information as required in the blanks provided and include:

   1. (A) Goods or services sold;
   2. (B) Sold to;
   3. (C) Sold by; and
   4. (D) Relationship of CBEC member to seller; and
7. (7) CBEC member signature.