; (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— (i) develop a claim form that claimants shall use when submitting claims under paragraph (1); and (ii) ensure that the form developed under clause (i) can be filed electronically. (B) Contents The form developed under subparagraph (A) shall request information relating to the claim of the claimant, including information relating to— (i) economic loss that the claimant suffered as a result of the discharge under section 101 of the debt of the Commonwealth of Puerto Rico and the instrumentalities of the Commonwealth of Puerto Rico; (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); (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