The sworn statement form required by §523.052(b)(2), Business & Commerce Code, must include:(1) a notice, at the top of the first page, that provides that:(A) the customer must file a police report regarding an offense under §32.51, Penal Code; and(B) the customer must return the completed sworn statement with either:(i) the incident or case number of the police report; or(ii) a copy of the police report.(2) blanks for the customer to provide:(A) customer's name, address, phone number, date of birth;(B) the number and the issuing governmental entity's name for the customer's:(i) driver's license or state issued identification card; or(ii) if the customer does not have a driver's license or state issued identification card, other government-issued identification.(C) the account number of any account compromised by the alleged offense and closed in response to the alleged offense;(D) routing number for the financial institution where the account was closed;(E) numbers or the range of numbers of any checks that have been lost, stolen, or compromised, if any;(F) the incident or case number of the police report; and(G) a signature before a notary public.