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.