Application Form

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 their section.

Survivor Information

Full Name

Age

Mailing address

City

, State Zip

Daytime phone

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 Zip

Daytime phone

Name

Relationship to survivor

Mailing address

City

, State Zip

Daytime phone

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 Zip

Phone

Name of Victim Advocate or DA's Assistant

Victim Advocate Phone

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.

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