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(e) Each person holding a certificate issued under this part shall provide a written report of each motor vehicle action to the FAA, Civil Aviation Security Division (AMC-700), P.O. Box 25 810, Oklahoma City, OK 73 125, not later than 60 days after the motor vehicle action. The report must include:
(1) The person's name, address, date of birth, and airman certificate number;
(2) The type of violation that resulted in the conviction or the administrative action;
(3) The date of the conviction or administrative action;
(4) The State that holds the record of conviction or administrative action; and
(5) A statement of whether the motor vehicle action resulted from the same incident or arose out of the same factual circumstances related to a previously reported motor vehicle action.