The application shall be made on the electronic form on the Department of Industrial Relations web site and shall include a declaration under penalty of perjury that the information provided is true and correct. The application shall contain the individual's first name, last name and middle name, social security number or tax ID number, address, telephone number and email address, if available, and the ADJ number of any workers' compensation cases filed by the individual, and the individual shall submit a .pdf or .tiff of the Voucher as an attachment to the application. The individual shall indicate whether the individual is a California resident or a non-resident.