§ 56B.051. APPLICATION FOR COMPENSATION.

(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.