C. The report form provided or approved by the sheriff or his designee shall include at least all of the following:

1. 1. The last, first and middle name of the pledgor or seller.
2. 2. The permanent address and telephone number, if applicable, of the pledgor or seller.
3. 3. The physical description of the pledgor or seller including height, weight, hair and eye color, sex, race and date of birth.
4. 4. The number and type of the identification document presented by the pledgor or seller.
5. 5. An accurate, legible description of each item pledged or sold, including the manufacturer's name, model number, serial number, caliber, size, type of item and any owner applied number, inscription or monogram.
6. 6. The pawnbroker's name and address and the clerk's initials or identifying number.
7. 7. The date and time of the initial pawn or purchase transaction.
8. 8. The type of transaction and initial pawn ticket number.
9. 9. A fingerprint of the pledgor or seller.

D. The pledgor or seller shall sign the report and attest to the following statement that shall appear on the report in ten point bold type:

All information in this report is complete and accurate. I am the owner of the goods described in this report or I am authorized to enter into this pawn or sale transaction on behalf of the owner of the goods described in this report. I understand that I will be guilty of a class 1 misdemeanor if the information in this report is not complete and accurate, if I am not the owner of the goods pledged or sold or if I am not authorized to enter into the pawn or sale transaction on behalf of the owner of the goods.