; (B) state the factual basis, as certified by the claimant, for eligibility for compensation and the amount of compensation sought; and (C) provide evidence that corroborates the eligibility of the claimant for compensation and the amount of compensation sought. (2) Claim form (A) In general The Special Master shall develop a claim form that claimants shall use when submitting claims under paragraph (1). The Special Master shall ensure that such form can be filed electronically. (B) Contents The form developed under subparagraph (A) shall request information including information regarding— (i) economic loss that the claimant suffered as a result of the discharge of the debt of the Commonwealth of Puerto Rico and the instrumentalities of the Commonwealth of Puerto Rico under section 101; (ii) collateral source compensation the claimant has received or is entitled to receive as a result of the discharge described in clause (i); and (iii) availability of financial guaranty insurance coverage to indemnify the claimant. (C) Penalty A claim submitted on the form developed under subparagraph (A) shall— (i) be submitted under penalty of perjury; and (ii) include an attestation by the claimant that the claimant has not willfully attempted to evade or defeat the eligibility restrictions described in subsection (c). (b) Review and determination (1) Review The Special Master shall review a claim submitted under subsection (a) and determine— (A) whether the claimant is an eligible person under subsection (c); and (B) with respect to a claimant determined to be an eligible person under subsections (c)(2)(A) and (c)(3)— (i) the extent of the economic loss to the claimant; and (ii) the amount of compensation to which the claimant is entitled based on the economic losses to the claimant, the facts of the claim, and the individual circumstances of the claimant, including— (I) the strength of the ties to the Commonwealth of Puerto Rico, as defined in regulations promulgated under section 206, of the claimant