(a) An applicant for compensation under this chapter must apply in writing on a form prescribed by the attorney general.
(b) An application for compensation under this chapter must be verified and contain:
(1) the date on which the criminally injurious conduct occurred;
(2) a description of the nature and circumstances of the criminally injurious conduct;
(3) a complete financial statement, including:
(A) the cost of medical care or burial expenses and the loss of wages or support the claimant or victim has incurred or will incur; and
(B) the extent to which the claimant or victim has been indemnified for the expenses under Paragraph (A) from a collateral source;
(4) a statement indicating the extent of any disability resulting from the injury incurred;
(5) an authorization permitting the attorney general to verify the contents of the application; and
(6) any other information the attorney general requires.