Vision Justice for all crime victims. Mission Statement With compassion and respect, we assist victims of sexual homicide, and other violent crimes through crisis response, advocacy, therapy, and community awareness. Start by Believing: Start by Lt A Public Awareness Believing Campaign to Change the Way We Respond to Sexual Violence in Our Community... one response at a time. YOUR REACTION MAKES THE DIFFERENCE. When someone tells you they've been raped, there's a simple response. Start by Believing. Seta \. “TTY: (561)992-1113... -» Vietiin Services Division : www.pbcgov. com/publicsafetyivictimsetices 24/7- SEXUAL ASSAULT. VIOLENT CRIME HELPLINE HELPLINE: (561)°833-7273 TOLL FREE: (866) 891-7275 ig Mein: Gotirthouse , 205 North Dixie Hwy., Suite 5.1100 West Palm Beach, FL 33401 (561) 355-2418 option 3 TTY: (561) 233-2595 Victim Services SART Center > 4210 North Australian Ave ’ . West Palm Beach, FL 33407 (561)'625-2568 option T a __ TTY: (561) 624-6520 + North County Courthouse. 3188 PGA Blvd., Suite 1436 Palm Beach Gardens, FL 33410 (561) 355-2418 option3 ~~ - TTY: (561) 624-6643 South County Courthouse 200 West Atlantic Aye., Suite 1E-301 Delray Beach, FIT33444 2tac2., (561) 274-1500 TTY: (561) 274-1015 West F County-Glades Courthouse 2976 Sate Réad 15, 2nd Floor Belle Glade, FL 33430 © (561) 996-4871 Like Us on Ei PBCVictimServices " Sexyites afe funded through Palm Beach County Board of County.Commissioners with grants from the Office of the . Attorney General and Flotida Council Against Sexual Violence Palm Bea h Courts Public Safety Department Victim Services Division EFTA00006055 —

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Do’ You Experience Any Of The Following? ® Inability to fall or-stay asleep? *, Feeling anxious or depressed? * Having outbursts of anger? * Inability to concentrate? * Feeling emotionally numb? * Loss of interest in the things you_used to enjoy? * Painful memories of the traumatic event? * Bad dreams about the traumatic event? ® Flashbacks or a sense of reliving the events? * Racing thoughts? , * Physiological stress response to reminders of the event? (pounding heart, rapid breathing, nausea, muscle tension, sweating) Palm Beach County provides equality of services and care to everyone, regardless of people's age, disability, gender, gender identity, race, religion or belief or sexual orientation. . " . . ~ Meeerices taciude iniltvidual therapy for children and adults and adult-support groups. If you are a crime victim or have been a victim of crime in the past and are considering therapy, we welcome your call. Therapists are available for appointments Monday through Friday, excluding legal holidays. ~ Therapists Will Help You: Identify trauma reactions Explore the impact that trauma has on your daily life Reduce the intensity of negative emotional fesponses and symptoms Learn about common trauma reactions and phases in healing Feel hopeful and positive regarding the future Develop coping mechanisms to utilize when thinking or talking about the crime Experience a reduction of trauma symptoms Return to work or school Explore the impact on current and future relationships @ Assessment and treatment for child victims | of crime Therapeutic interventions that teach child safety Play Therapy @ Assistance for parents during this difficult time Signs Of Trauma In Children Sadness: The child may feel despondent or hopeless. The child may cry easily or withdraw! isolate from others. Loss of interest in activities: The child may complain of feeling “bored” or reject offers to participate in activities they have previously enjoyed. Anxiety: The child may become anxious and, tense, and feel panic. Turmoil: The child may feel worried and irritable. The child may lash out in anger resulting from the distress he/she is feeling. @ Regression: The child may revert to acting like a baby, bedwetting, clinging and demanding extra care. EFTA00006056

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Vision Justice for all crime victims. Mission Statement With compassion and respect, we assist victims of sexual assault, domestic violence, homicide, and other violent crimes through crisis response, advocacy, therapy, and community Florida Statute 960 Provides Guidelines For Fair Treatment & Specific Rights For Victims In The Criminal Justice System Some of these include the following: Office of Attorney General Crime Victim Compensation, when applicable; ~ To be informed, present, and heard, when relevant at all crucial stages of criminal or juvenile proceedings, to the extent that right does not interfere with the Constitutional rights of the accused; ~ To be provided information concerning services available including Victim Compensation, community treatment programs, crisis intervention services, counseling and social services; Toa prompt and timely disposition of the case, to the extent that this right does not interfere with the Constitutional rights of the accused; ~ To have your property returned to you as soon as possible after the investigation and/or prosecution is completed, unless there is a compelling reason for its retention; Have a Victim Advocate present during depositions of the victim; Request, for specific crimes, an exemption prohibiting the disclosure of information to the public which reveals your identification. Palm Beach County Public Safety Department Victim Services Division www. pbcgov.com/publicsafety/victimservices 24/7 SEXUAL ASSAULT VIOLENT CRIME HELPLINE HELPLINE: (561) 833-7273 TOLL FREE: (866) 891-7273 Main Courthouse 205 North Dixie Hwy., Suite 5.1100 West Palm Beach, FL 33401 (561) 355-2418 option 3 TTY: (561) 233-2595 Victim Services SART Center 4210 North Australian Ave. West Palm Beach, FL 33407 (561) 625-2568 option 1 TTY: (561) 624-6520 North County Courthouse 3188 PGA Bivd., Suite 1436 Palm Beach Gardens, FL 33410 (561) 355-2418 option 3 TTY: (561) 624-6643 South County Courthouse 200 West Atlantic Ave., Suite 1E-301 Delray Beach, FL 33444 (561) 274-1500 TTY: (561) 274-1015 West County-Glades Courthouse 2976 State Road 15, 2nd Floor Belle Glade, FL 33430 (861) 996-4871 TTY: (561) 992-1113 Services are provided to all crime victims in Palm Beach County regardless of the victims’ race, sex, color, religion, national origin, disability, age, sexual orientation, marital status, or gender identity or expression. Services are funded through Palm Beach County Board of County Commissioners with grants from the Office of the Attorney General and Florida Council Against Sexual Violence. Lee Palm Beach County Public Safety Department Victim Services Division Victim Services & Certified Rape Crisis Center Serving Victims of Violent Crimes EFTA00006057

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Services Provided Professional training and community presentations are also available. Information about Victims’ rights ~ 24-hour crisis response to hospitals, law enforcement agencies and crime scenes + Sexual Assault Nurse Examiner (SANE) and a Forensic Exam site ~ The Butterfly House Sexual Assault Response Team (SART) ~ to provide Victim-centered assistance Criminal Justice advocacy and court accompaniment + Assistance with filing State Crime Victim Compensation applications and Restraining Orders * Individual therapy and support groups * Information and referral to community resources, including shelters and Legal Aid — Palm Beach County provides equality of services and care to everyone, regardless of people's age, disability, gender, gender identity, race, religion or belief or sexual orientation. Sexual Assault Sexual Assault is a violent crime including rape, incest, sexual harassment or any other sexual contact without consent. Per Florida Statute 90.5035, a victim of sexual violence who consults a sexual assault counselor at a rape crisis center has the right to confidentiality of information shared with the counselor. No one except the victim can compel the sexual assault counselor to reveal information about their communications. Only the victim can waive the privilege, and this must be done in writing. If rape victims are not sure whether to report to law enforcement, victim advocates will assist them through their decisionmaking process, respecting whatever choices are made. Certified Rape Crisis Victim Advocates Will Provide: Crisis Intervention and Personal Advocacy Accompaniment during forensic rape exams at The Butterfly House and other medical facilities Coordination of follow-up medical care, therapy and referrals ~ Criminal Justice advocacy and court accompaniment mum, Start by Believing: A Public Awareness Campaign to Change Start by the Way We Respond to Sexual Violence in Our Community... Believing one response at a time. YOUR REACTION MAKES THE DIFFERENCE. When someone tells you they've been raped, there's a simple response. Start by Believing. Domestic Assault Domestic Assault involves power and control tactics such as physical violence, emotional abuse, sexual violence, economic abuse, and isolation. Victim Advocates Will Provide: + Crisis Intervention + Safety Planning * Assistance with filing Restraining Orders Safe-Shelter Referrals > Personal and legal advocacy during criminal justice proceedings Homicide and Other Violent Crimes Homicide and other violent crimes shatter the lives of injured victims and survivors causing severe emotional trauma and grief. Victim Advocates Will Provide: ¢ Crisis Intervention and emotional support for victims and surviving family members Assistance with filing crime victim compensation for medical expenses, funeral costs and loss of support ~ Court Accompaniment Referrals for individual therapy, support groups and community assistance TREE Oe LT EFTA00006058

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Sexual Battery is a Crime! Victims of sexual crimes need compassion, sensitivity and empathy. Being the victim of a crime can be overwhelming. Your reactions are normal. Local certified rape crisis centers have advocates who are there to help all victims, regardiess of whether or not they report to law enforcement. Services are free and confidential — certified rape crisis centers are legally and ethically required to protect your confidentiality, unless you allow, in writing, the release of your information. Advocates are available to: ® Provide crisis intervention ® Speak to you on the 24-hour hotline ® Discuss your options ® Navigate available resources = Go with you to appointments = Address safety concerns ® Advocate on your behalf ® Help you apply for victim compensation In Florida, the legal term for rape or sexual assault is sexual battery (F.S. 794.011). Sexual battery means oral, anal, or vaginal penetration by, or union with, the sexual organ of another or the anal or vaginal penetration of another by any other object, committed without your consent. Consent means intelligent, knowing, and voluntary consent and does not include coerced submission. Failure to offer physical resistance to the offender does not imply consent. A person under 16 years of age cannot legally consent to sex. Also, a person 24 years of age or older or a person in a familial or custodial position of authority cannot receive consent from 16 and 17 year old minors. What is a forensic exam? The forensic exam is a head-to-toe exam to collect evidence and check for injuries after a sexual crime. What are my rights with regard to the exam? = Stop the exam at any time = Have an advocate from a rape crisis center with you = Be informed about the status of the kit during processing What evidence is collected? During the exam, the medical professional may collect blood, urine, saliva, pubic hair combings and/or nail samples. They may also collect items of your clothing. They will ask you questions about the crime and your medical history in order to help them collect evidence. What happens to the evidence? If you make a report to law enforcement, your kit will be sent to the regional or statewide lab within 30 days for testing. The lab is required to process the kit within 120 days. If you don't report the crime to law enforcement at the time you obtain the exam, your kit will be stored anonymously. Your kit may be stored for only a limited time, depending on your community's storage space. The local rape crisis center can advise you EFTA00006059

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You have the right to: ® Obtain a forensic exam whether or not you report to law enforcement = Have an advocate at the forensic exam with you = Have the forensic exam sent for testing within 30 days, if reported to law enforcement = Review the law enforcement report prior to final submission = Be informed, present, and be heard at all crucial stages of the criminal or juvenile proceeding = Have an advocate with you during a discovery deposition ® Have identifying information about the criminal investigation kept confidential = Have the offender, if charged, tested for HIV and hepatitis ® Attend sentencing or disposition of the offender ® Notification of judicial proceedings and scheduling changes = Notification about the release of incarcerated offender = Request restitution = Give a victim impact statement = Not be subjected to a polygraph = Take up to 3 days of leave from work (with eligible employer) = Apply for an injunction if you fear for your safety or offender is nearing release ———_ : You may be eligible for financial assistance for: = Medical Care = Lost Income = Mental health services ® Relocation = Other expenses related to injuries as a result of the crime Contact your local certified rape crisis center for more information. This project was supported by Grant No. 2015-WL-AX-0037 awarded by the Office on Violence Against Women, U.S. Department of Justice. The opinions, findings, conclusions, and recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the Department of Justice, Office on Violence Against Women. Florida Council Against Sexual Violence 1-888-956-7273 www.fcasv.org Victim Compensation 1-800-226-6667 www.myfloridalegal.com Florida Department of Law Enforcement Sexual Offender/ Predator Unit 1-888-357-7332; 1-850-410-8572 For TTY Accessibility: 1-877-414-7234 E-mail: sexpred@fdle.state.fl.us Florida Department of Corrections Victim Information and Notification Everyday (VINE) 1-877-VINE-4-FL www.dc,state.fl.us/oth/victasst/index.htm! Florida Abuse Hotline 1-800-962-2873 Local Rape Crisis Center Palm Beach County Victim Services & Certified Rape Crisis Center Victim Services SART Center 4210 North Australian Avenue West Palm Beach, FL 33407 Office: 561-625-2568 Helpline: 866-891-RAPE (7273) www.pbcgov.com/publicsafety/ victimservices Maech 2017 - 4000 EFTA00006060

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, ) Cenier for Trauma Counseling ; Yi, Where Your Emotional Healing Can Begin A non-profit Community Counseling Center Serving Palm Beach County and beyond Individual, Couples, Family, & Group Therapy Services for Children (3 y/o) to Adults (99 +) We offer affordable counseling services to those that are insured and not insured. Insurance accepted: Cigna, Humana Commercial, Magellan, Beacon (Humana Medicaid, Coventry) Sliding Scale: Reduced fees based on income for those who qualify Languages Spoken: English, Spanish, and Farsi Evidence Based Models: Play/Sand Tray therapy, EMDR, Trauma Focused Cognitive Behavioral Therapy Hours: Monday-Friday, Saturdays and evening appointments available Referral Process: Call 561-444-3914 (Office) email: info@palmbeachmentalhealth.org Center for Trauma Counseling, Inc. 6801 Lake Worth Road, Suite 307 Greenacres, FL 33467 Office: 561-444-3914 www.palmbeachmentalhealth.org EFTA00006061

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Office of the Attorney General The Capitol, PL-01 + Tallahassee, FL 32309-1050 © Office: (800) 226-8687 Fax: (850) 414-6197 Bill Status Information for Providers (850) 444-3331 © TDD users may call through Florida Relay Service at 1-800-055-8771 Website: myfloridalegal.com * Email address: vcintake@myfloridalegal.com BUREAU OF VICTIM COMPENSATION CLAIM FORM Instructions Please read the Eligibility Requirements to see if you qualify for this program Fill out this form completely (please print), attach all required documentation, and submit to the above address. If you move or change your address, you are required to notify this office. CHECK THE TYPE OF VICTIM COMPENSATION BENEFITS YOU ARE REQUESTING: [F) SOPOR ceeeeeste bs to tile ae Seni s ee ee EXPENSES - payment or reimbursement on behalf of the victm for crme-retated (Attach documentation as outlined in Section 3.) funeral/burial, medical/dental treatment, and mental health counseling expenses; as well as prescriptions, eyeglasses, dentures, or a prosthetic device lost, WAGE LOSS - compensation for the victm who lost wages due to crime related ; ‘ injuries. (Attach documentation as outlined in Section 3,) par per ag Ho pee 8S OF SUPPORT - compensation for the dependent{s) of a deceased victim [PEL NTAL AL HEALTH/GRIEF ‘who was employed at the time of the crime. (Attach documentation as oufined TREATMENT COUNSELING in Section 4.) Oo EMERGENCY ASSISTANCE - reimbursement for documented wage loss and out-of-pocket expenses related to the crime, (Attach receipts.) CHECK ALL OTHER TYPES OF BENEFITS YOU ARE REQUESTING: (Separate claim numbers wil be assigned.) [| SRY L008 cata a Be On te a et seal Epon tose eaepartreagae set peten proof of disability prior to the data of crime from @ physician or the Social Security domestic violence seeking assistance to relocate to @ safe environment. A Administration) who sufiered the loss of tangible personal property as the result certified domestic violence certification form and application must be receved of a criminal or delinquent act. Attach a receipt ot written estimate from a vendor within 30 days from the date of crime. or merchant identifying the comparable replacement value. Compensable items must be identified by the law enforcement report. De pr fin eer pre preterm heyy trafficking with an urgent need to relocate. Arape crisis or domestic violence SEXUAL BATTERY RELOCATION ASSISTANCE - for the victim of sexual center certification form and application must be received within 45 days of the battery seeking assistance tp relocae due to reasonable fear. A certified rape last identifiable threat. crisis center certification form must be received with the application Section 1. Victim and Applicant Information THIS INFORMATION IS COLLECTED FOR FEDERAL REPORTING PURPOSES AND IS OPTIONAL. |__| NATIVE HAWAIIAN or OTHER PACIFICISLANDER | | OTHERRACE RACE/ETHINICITY: [enon INDIAN! i ht CL BLACK/AFRICAN HISPANIC or ALASKA NATIVE AMERICAN LATINO WAS VICTIM DISABLED BEFORE THE CRIME OCCURRED? The applicant fling on behalf of a victim is required to provide claimant information below. When requesting compensation on behait of an incompetent adult victim, proof of legal guardianship must be attached, and the applicant's signature on the aim form must be witnessed by a Notary Public. IS THE VICTIM (check ove) [_] veceasen [_] muuren minor ae [_] neomeetenr APPLICANT NAME 7 DATE OF (last frst riddle) BIRTH WOULD YOU LIKE ALL CORRESPONDENCE SENT BY EMAIL? Cs [)» ZIP cITy CODE | RELATIONSHIP MABER ( ) TO VICTIM NUMBER BVC 100 (7/15) The Office of the Attorney General, Bureau of Victim Compensation is an equal opportunity provider and employer. Page 1 of 4 EFTA00006062

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' Section 2. Referral Source Information individuals who assisted with or filed out any sections o this application are required to provide referral information below. By signing this application, the victinvapplicant affirms that all information provided is true and correct, and thus, all sections should be reviewed before the application is signed. (Treatment providers can request training on the Victim Compensation Program, which is recommended prior to becoming a referral source.) NAME OF PERSON ASSISTING WITH APPLICATION E-MAIL first, middie) ADDRESS NAME OF AGENCY/ORGANIZATION : address, code) NUMBER Section 3. Disability or Lost Wages Information Thon reaneaiy carponcaion bret wages elach a copy of your pay a or eaigs siement which defies you erployent statis and wages athe te ofthe ine you se sek enployed er werk fa fordymontber attach a copy of your leestinccme tax eum and appcabe IRS schedule ors. F more han S wor day were missed as aves the cme, atacha dots eer which excuses your his abserce. When requesing dsabity compensation, atch a doc’ llr which species each cme read permanent dsabityrairg accordng b he Amercan Medical Assoriaficn Guidelines or Florida Impairment Rating Guidelines, and forward Social Securty Administration award letiers. SUPERVISOR'S NAME TELEPHONE NUMBER NAME OF COMPANY/BUSINESS more han one attach additonal Section 4. Loss of Support Information or Grief Counseling Information indicate the name(s) and date(s) of birth of the deceased victim's surviving spouse, parent, sibling, or chid. For loss of support, attach a copy of the deceased victim's relationship, marriage certificate, or legal documentation proving principal support. DEPENDANT/MINOR CLAIMANT NAME(S) DATE OF BIRTH RELATIONSHIP TO VICTIM i a a a EE ee gt et eee a ian af oe Secs Se iy ae ee a eee Section 5. Insurance Information Clamanis who are determined eligible for he Vicim Compensation and Property Loss Programs may be exempt from the insurance deductible or co-payment provisions of their insurance policy(ies). IS INSURANCE OR MEDICAID AVAILABLE TOASSIST WITH THESE EXPENSES? 0 yes 0 no MEDICAID NUMBER: Ityes, provide the following for all Insurance policies, inchuding Medicaid Medicare, fo, homeowner's, automobile, or majer medical. Attach ail related insurance Explanation of Benefits staterent(s). 0- 119-2584 Section 6. Other Compensation, Settlement, and Attorney Information You must rolfy ts offce f you have received. orf you anficipale recsiving compensation or any benefits from any other source 2s @ result of tis incident. You must also notify this office if you have or are planning to hire an attomey to represent you as a resul of the incident ARE YOU REPRESENTED BVC 100 (7/15) The Office of the Attorney General, Bureau of Vietim Compensation is an equal opportunity provider and employer. Page 2 of 4 ~- EFTA00006063

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i Section 7. Crime Information This section must be completed and proof of crime (such as a law enforcement report or charging affidavit) must be attached. Failure to submit proof of crime wall result in your application not being processed or your claim being denied. NAME OF LAW DATE OF DATE REPORTED TO LAW ENFORCEMENT AGENCY CRIME ENFORCEMENT AGENCY WAS THE CRIME REPORTED TO LAW ENFORCEMENT WITHIN 72 HOURS? YES NO Hf no, please explain. (no, failure to provide an acceptable explanation inthis secon wil result in a deni of benef ts.) Tne sleeve expla. Pave be edvied thal most benefits apply to resiment losses suflered win one year om the date of creme, with some excapons for miner Wins. Hf no, failure to provide an acceptable explanation inthis section will result in 2 denial of benefits.) Section 8. Eligibility Requirements Vietin Compensation (VC): The victim must cooperate fuly wit law enforcement ofcials, State Atomey’s Offce, and the Attomey Generaf Offic, The cime must be repeted to law enforcement within 72 hours, unless thre s good cause for delayed reporting. The claim must be fled within one year ater the date atthe erie or within two years when there is good reason for not fling within one year. Exceptions fr fling time requirements apply to victims who are minors. The victim must not have engaged in an unlawful activity or contributed tothe situation that brought about his or her own injury or death. The victim must have suffered a physical, psychiatric, psychological injury, or death as a result of the crime. Property Loss (PL): The victim must have suffered a substantial diminution in ther quality of He from the loss of tangible personal property a he resut of @ criminal or delinquent act. Property loss reimbursement is available up to $500 on any one claim and a lifetime maximum of $1,000 on all claims. Domestic Violence Relocation Assistance (DV): The victim must need immediate asistance to escape a domestic violence environment. The application must be fled within 30 days after the domestic violence crime. Certification by certified domestic violence center in the State of Florida is required. The vicim must submit estimates, invoices, ot receipts for interim lodging, housing, utlty deposits, new cellular phone service, transportation, moving company expenses, or emergency food or clothing. phone service, transportation, moving company expenses, or emergency food or clothing. Human Trafficking Relocation Assistance (HT); The vitim must have an urgent need to escape from an unsafe environment direct related to @ sexual human trafficking offense. Application must be received within 45 days ofthe last identifiable threat by @ human trafficking offender. The identifiable threat must have been communicated with the proper authorities. Certification from a certified rape crisis or domestic violence center in the State of Florida is required. The victim must submit estimates, invoices or receipts from interim lodging, housing, utility deposits, new cellular phone service, transportation, moving company expenses, or emergency food or clothing. Criminal History Record Check: In order for compensation to be considered, the victim or applicant must not have been confined orn custody in @ county or municipal fact, 2 state or federal correctional feciity; ora juvenile detention commitment, or assessment facility; adjudicated as @ habitual felony offender, habitual violent offender, or violent career criminal; or adjudicated of a forcible felony offense. Notice of Payment Limitations: The Bureau of Vicim Compensation may provide nancial assistance for egble persons, but only aftr al other sources o . payment have been exhausted Payments accepted by in-state provders on behalf of vicims are considered paymentnful per Florida Statute, Total icin aempensation benefs cannot exceed the maximum award amount determined by the curent benefit payment schedule. Limits below the maximum may apply 1 specific benefits, which may be reduced without prior notice to the award recipient based on the availability of funding. Acceptable Proof of Crime: The Bureau of Victm Compensation does not make an independent judgment on whether a compensable crime occured, Wit instead relies on proof of crime from the proper authorities. Failure to provide acceptable documentation proving that a compensable crime occurred shall result in your application not being processed or your claim being denied. ‘Acceptable documentation includes: a law enforcement report or charging affidavit from a child protecton team, law enforcement agency, slate or prosecuting atlomey, or the Department of Cdren and Familes tht affirms a compensabie cre a ccurred: an indictment by a grand jury, an indiciment by @ prosecutor from cout of competent jurisdiction; a report from the United States Federal Bureau of Investigation; or a Florida Department of Law Enforcement cybercrime investigator certification ofa crime for purposes of Section 960.197, FS. Complete Application Package: Its your responsibility to provide a complete application package which incides acceptable documentaion proving ‘hats crime pocumed. Ifthe department receives a report which is insufficient for proving that a compensable crime occurred, the application willbe assigned @ claim number and denied. Claim numbers assigned are not indicative of eligibility or denial. For assistance with collecting acceptable documentation, please contact your local law enforcement agency, the agency where the cme was reported, the referal source, or your local State Attomey's Office. BVC 100 (7/15) The Office of the Attorney General, Bureau of Victim Compensation is an equal opportunity provider and employer. Page 3 of 4 EFTA00006064

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PLEASE READ CAREFULLY AND SIGN THE FOLLOWING CERTIFICATIONS Section 9. CONFIDENTIALITY: If you are the victim of a sexual battery, aggravated child abuse, aggravated stalking, harassment, aggravated battery, or domestic violence, you have the right to have information about your home address and telephone number, employment address and telephone number, end your personal assets, kept confidential for a period of five years. If you are the victim of any of these crimes, please mark one of the following statements. Your response will not the processing of your claim. I want the information to be confidential [C1 1 do NOT want the information to be confidential SERIOUS FINANCIAL HARDSHIP: | certify that | have a serious financial hardship because of crime-related expenses that cannot be paid by any other source. PROPERTY LOSS CERTIFICATION: \ certify that the property In question belonged to the victim; that this loss adversely affects the victim's quality of Ife; that there is no other source of reimbursement for this loss; and that replacement of the property would cause the claimant a serious financial hardship. RELEASE OF INFORMATION: | give permission to any hospital, doctor, dentist, mental health counselor, or other treatment provider, banking institution, social service agency, law enforcement agency, corrections agency, state atiorney’s office, insurance carrer, attorney or employer to give out information that is requested concerning any treatment rendered, employment, insurance, third-party payer, or law enforcement investigative information to the Department of Legal Affairs for use in processing my claim. | give permission to the Department to release information atout the status of my claim to any treatment provider, law enforcement agency, or state attomey’s office. SOCIAL SECURITY NUMBER DISCLOSURE: The Bureau of Victim Compensation collects and uses Social Security numbers for the purpose of performing imperative duties and responsibilities which may include the folowing: searching criminal history records, identity management, bling and payments, benefit processing, and reporting to authorized state and federal goverment agencies. Failure to provide this opticnal information may delay the processing of your application or benefits. Federal and State laws require the Bureau to protect Social Security numbers from disclosure to unauthorized parties. Absent a waiver from you or your legal representative Social Security numbers will be redacted, unless the agency receives a court order to turn over a non redacted file. REPAYMENT REQUIREMENT: | understand that payment by the victim compensation program is a payment of last resort and that | must repay the Crimes Compensation Trust Fund if I receive a victim compensation award and also receive payment from another source as a result of the same criminal incident Other sources include, but are not limited to, any payment from the offender, an insurance polcy, a settlement, a judgment or an award in a third party lawsuit. [further understand that | must repay any emergency award from the Crimes Compensation Trust Fund, if my claim is determined ineligible. | also understand that if my eligibility is withdrawn, | must repay any amount received from the Crimes Compensation Trust Fund. VICTIM: Must be signed and dated by the victim if filing as a competent adult. and correct to the best of my knowledge. APPLICANT: Applicant signature is required if filing as the parent, legal guardian, or individual authorized to administer a victim's estate. Printed Name: EEE Signature: Date: Under penalty of perjury or fraud, the information I have provided is true and correct to the best of my knowledge. NOTARIZATION REQUIREMENT: Persons submitting an application on behaif of an incompetent adult must submit proof of legal guarcianship and have their signature witnessed by a Notary Public. Sworn to and subscribed before me this day of (C) Personally known to me. (D1 Identification produced. Notary Public Signature: BVC 100 (7/15) The Office of the Attorney General, Buroau of Victim Compensation is an equal opportunity provider and employer. Page 40f4 EFTA00006065