The form for a fund claim shall be executed under penalty of unsworn falsification and must include


(1) the name and address of each 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.