The form for a fund claim shall be executed under penalty of unsworn falsification in the second degree and must include
- (1) the name and address of each mortgage loan originator licensee involved;
- (2) the amount of the alleged loss;
- (3) the date or period of time during which the alleged loss occurred;
- (4) the date when the alleged loss was discovered;
- (5) the name and address of the claimant; and
- (6) a general statement of the facts related to the fund claim.