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.

Source Note: The provisions of this §35.54 adopted to be effective January 3, 2008, 32 TexReg 9940; amended to be effective September 9, 2010, 35 TexReg 8102