When an impound condition is imposed, the franchiser shall deliver to each franchisee or subfranchisor, a purchase receipt, in the following form: The purchase receipt form shall provide space for at least: (1) the complete names and addresses of the purchaser; (2) the complete name of the individual receiving the payment; (3) the general location of the franchise involved and the total purchase price; (4) the amount of the payment received; (5) the complete name and address of the depositary with whom the payment will be placed; and (6) the date of the payment. Purchase receipt forms shall be consecutively numbered and prepared in triplicate. The original copy is to be given to the purchaser. The duplicate copy is to be retained by the franchiser. The triplicate copy is to be provided to the depositary along with the payment involved.