Online Application The application should be submitted after an indictment is made and a trial date has been set. The victim should complete this Form, and have the district attorney fill out and sign their section.
Survivor Information Full Name Age Mailing address City , State Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Daytime phone Email What was your relationship with the perpetrator (Stranger, family member, etc.)? Relationship with perpetrator Please describe the incident in as much detail as possible. This information will remain confidential and will only be used for statistical purposes: Please describe the incident Information on parents, guardian, friend who will be accompanying you to trial if accepted (maximum of two individuals): Name Relationship to survivor Mailing address City , State Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Daytime phone Email Name Relationship to survivor Mailing address City , State Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Daytime phone Email Financial Information *Annual household income $.00 *Total savings $.00 Number of dependents *Note: Income and savings statement will not necessarily affect application. We request this information because the Foundation has a limited amount of funding to distribute at any given time, and we may sometimes have to prioritize based on financial need. Information disclosed will be kept confidential. Any special circumstances you would like our application committee to be aware of: (attach additional page if needed) District Attorney's Office Name of prosecutor Jurisdiction/County Mailing address City , State Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Phone Email Name of Victim Advocate or DA's Assistant Victim Advocate Phone Email Name of accused Case name Docket number Has an indictment been entered? YES NO Please list charges brought Trial date Prosecuting Attorney Title Signature _____________________________________ The survivor may wish to attach news articles and/or a letter explaining the circumstances, but this is not required. Please obtain the appropriate signatures (both pages), and then mail or fax completed application to address listed above. All expenses are to be verified by receipts. How did you find us?
*Note: Income and savings statement will not necessarily affect application. We request this information because the Foundation has a limited amount of funding to distribute at any given time, and we may sometimes have to prioritize based on financial need. Information disclosed will be kept confidential. Any special circumstances you would like our application committee to be aware of: (attach additional page if needed)
