A bail bondsman who collects a premium shall provide a numbered receipt to the person paying the premium. A copy of the receipt shall be retained by the bail bondsman and maintained in accordance with Regulation .10 of this chapter. A receipt shall contain the following information: The name, place of business, address, and telephone number of the bail bondsman who collected the premium; An itemized statement of the amount of bail and the jurisdiction for which the bond is being written; An itemized statement of the premium charged; The amount collected by the surety insurance producer; The unpaid balance, if any; The amount, value, and description of any collateral received; The following statement, in capital and bold letters of at least 12-point font, at the bottom of the receipt: THE PERSON PAYING THE PREMIUM MUST RECEIVE A COPY OF THIS RECEIPT AT THE TIME OF MAKING A PAYMENT; and The insurance producer license number and the printed and signed name of the bail bondsman collecting the premium.