Application Form

Please print or type

Section I
Rape Survivor Information

Full Name__________________________________________________________

Mailing Address______________________________________________________

City, State, Zip Code ________________________________________________

Daytime Phone _________________________ Email________________________

Signature __________________________________________________________

Section II
Information on parents, guardian, friend who will be accompanying you to trial if accepted (maximum of two individuals):

Please print or type

Full Name _____________________________________

Relationship to survivor __________________________

Their Full Mailing Address _____________________________________________

City, State, Zip Code __________________________________

Their Daytime Phone_________________ Their email____________________

Their signature ____________________________________

Full Name ___________________________________

Relationship to survivor ____________________________

Their Full Mailing Address ______________________________________________

City, State, Zip Code __________________________________

Their Daytime Phone_________________ Their email____________________

*Their annual household income__________________

Number of dependents________

*Their total savings ____________________________

*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)

Their signature _______________________________________

Section III
District Attorney's Office

Please print or type

Name of Prosecutor ____________________________________

Jurisdiction/County _____________________________________

Address ______________________________________________

_____________________________________________________

Phone ___________________ Email_________________

Name of accused ________________________________

Case name ___________________________ Docket number _____________

Has an indictment been entered? YES NO

Please list charges brought_________________________________

_______________________________________________________

_______________________________________________________

Trial date: ________________________________

Signature of Prosecuting Attorney_________________________________

Typed/Printed name _________________

Title_____________________________________

Date _________________

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 completed application and any accompanying material to:

It Happened to Alexa Foundation
904 Center Street,
Lewiston, New York 14092
Phone: (716) 754-9105
Fax: (716) 754-4676

All expenses are to be verified by receipts.

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