Health & Saf. Code, § 80925

(a) The Department of General Services shall prescribe appropriate forms and procedures for claims filed pursuant to this chapter, which shall include, as a minimum, all of the following:

(1) A provision requiring the claimant to make a sworn verification of the claim to the best of the claimant’s knowledge.

(2) A full description, supported by appropriate evidence from government agencies of the release of the hazardous substance claimed to be the cause of the physical injury or illness or loss of income.

(3) Certification by the claimant of dates and places of residence for the five years preceding the date of the claim.

(4) Certification of the medical history of the claimant for the five years preceding the date of the claim, along with certification of the alleged physical injury or illness and expenses for the physical injury or illness. The certification shall be made by hospitals, physicians, or other qualified medical authorities.

(5) The claimant’s income as reported on the claimant’s federal income tax return for the preceding three years in order to compute lost wages or income.

(b) Any person who knowingly gives, or causes to be given, any false information as a part of any claim pursuant to this chapter shall be guilty of a misdemeanor and shall, upon conviction, be fined up to five thousand dollars ($5,000), or imprisoned for not more than one year, or both.