EFTA00006055

county Palm Beach ti • '. Safety .Department 'Public Saki< Denali Intent Vision jiiiedin Services Division iclim Sci viucs Di% isio Justice for all crime victims. wwwpbcgov.com/publitsafety/victimSeeVicett Mission Statement With compassion and respect, 24/7 SEXUAL ASSAULT we assist victims of sexual evil- et, domestic violence, VIOLENT CRIME HELPLINE homicide, and other violent HELPLINE: (561 -8$3`7273 crimes through crisis response, TOLL FREE: (866) 891.7273 advocacy, therapy, and community awareness. 1:.N Eoi rehouse -'205 45itil Utile Hwy , Suite 5.1109 West Palm Beach. FL 33401 (561) 355-2418 option 3 TTY: (561) 233-2595 1 Victim Services SART Center Palm Beach County 42113 North Australian Ave. kilo. Vilest Palm Beach. FL 33407 Victim Services (561)625.2568 option 1 • is a Certified Rape Crisis Center . tr.; it TIT (561) 6244520 that provides therapy services to all crime victims in Palm Beach Noith County Courthouse County regardless of the victims' 3188 PGA Blvd.. Suite 1436 race, sex, color, religion, national Palm Beach Gardens, FL 33410: (561) 355-2418 option 3 ' origin, disability, sexual (561) 624.6643 orientation, marital status, familial status or gender identity South County Courthouse or expression. 200. West lykraje Ave., Suitt E-301 DenyW4aeh. (50) 274:1500 ITV: (561) 274-1015 es" West County-Glades Courthouse Start by Believing: 2976 $tate n&d 15. 2nd Floor Start by r A Public Awareness Belle Glade, FL 33430 Believing Campaign to (561) 996-4871 Change the Way ITV; (561)992-1113.._ -.- przvictimsgrytces We Respond to Sexual Violence in Our Community... one response at a time. YOUR REACTION --Like Us on MAKES THE DIFFERENCE. When someone tells you they've Sart-gifts are funded through Palm Beachtounty Board of been raped. there's a simple response. County Cornthissioners with grants fronithe OKI& of the - Start by Believing. AttorpeyGeneral and Honda Council Against Sexual Violence;;.,-. -0, Palm tescItCounly Sewing Victims of Violent Crimes N EFTA00006055 Have You Been ,. erapy For A Victim Of A Crime? Free services include individual therapy Children & Teenagers for children and adults and adult-support O Assessment and treatment for child victims Do' Thu Experience groups. of crime Any Of The Following? If you are a crime victim or have been O Therapeutic interventions that teach a victim of crime in the past and are child safety • * Inability to fall orstay asleep? considering therapy, we welcome your coll. .0 Play Therapy * Feeling anxious or depressed? Therapists are available for appointments .0 Assistance for parents during this * Having outbursts of anger? Monday through Friday, excluding legal difficult time * Inability to concentrate? holidays. * reeling emotionally numb? Signs Of lPauma In Children Therapists Will Help You: * Loss of interest in the things you used to enjoy? O Sadness: The child may feel despondent or O Identify trauma reactions hopeless The child may cry easily or withdraw/ * Painful memories of the traumatic event? isolate from others. O Explore the impact that trauma has on your daily life * Bad dreams about the traumatic event? O Reduce the intensity of negative emotional O Loss of interest in activities: The child may * flashbacks or a sense of reliving the events? responses and symptoms complain of feeling "bored" or reject offers to * Racing thoughts? participate in activities they have previously O Learn about common trauma reactions and enjoyed. * Physiological stress response to reminders of the phases in healing event? (pounding heart, rapid breathing, nausea, O Anxiety: The child may become anxious and, muscle tension, sweating) O Feel hopeful and positive regarding the future tense, and feel panic. O Develop coping mechanisms to utilize when thinking or talking about the crime O Turmoil: The child may feel worried and irritable. The child may lash out in anger O Experience a reduction of trauma symptoms resulting from the distress he/she is feeling. Palm Beach County provides equality of services and O Return to work or school O Regression: The child may revert to acting care to everyone, regardless of people's age, disability. like a baby. bedwetting, clinging and O Explore the impact on current and future gender. gender identity, race, religion or belief or demanding extra care. sexual orientation. relationships EFTA00006056 Palm Beach County Vision Public Safety Department Palm Beach County Victim Services Division Public Safety Department Justice for all crime victims. Victim Services Division www.pbcgov.comipublicsafety/victimservices Mission Statement 24/7 SEXUAL ASSAULT With compassion and respect, we assist victims of sexual assault, domestic violence, homicide, and other violent crimes through VIOLENT CRIME HELPLINE HELPLINE: (561) 833.7273 TOLL FREE: (866) 891.7273 Victim Services crisis response, advocacy, therapy, and community awareness. Main Courthouse 205 North Dixie Hwy., Suite 5.1100 West Palm Beach, FL 33401 & Certified Rape Crisis Center (561) 355-2418 option 3 Florida Statute 960 Provides TTY: (561) 233.2595 Guidelines For Fair lFeatment Victim Services SART Center & Specific Rights For Victims 4210 North Australian Ave. Serving Victims of Violent Crimes In The Criminal Justice System West Palm Beach, FL 33407 (561) 625.2568 option 1 Some of these include the following: TTY: (561) 624.6520 O Office of Attorney General Crime Victim North County Courthouse Compensation, when applicable; 3188 PGA Blvd., Suite 1436 Palm Beach Gardens, FL 33410 O lb be informed, present, and heard, when (561) 355-2418 option 3 relevant at all crucial stages of criminal or TTY: (561) 624.6643 juvenile proceedings, to the extent that right does not interfere with the Constitutional South County Courthouse rights of the accused; 200 West Atlantic Ave., Suite 1E-301 Delray Beach. FL 33444 0 lb be provided information concerning (561) 274.1500 services available including Victim TTY: (561) 274-1015 Compensation, community treatment pnagrams, crisis intervention services, West County-Glades Courthouse counseling and social services; 2976 State Road 15. 2nd Floor Belle Glade, FL 33430 0 lb a prompt and timely disposition of the case. (561) 996.4871 to the extent that this right does not interfere TTY: (561) 992-1113 with the Constitutional rights of the accused; Services are provided to all crime victims in Palm Beach 0- lb have your property returned to you as soon County regardless of the victims' race, sex. color, religion. as possible after the investigation and/or national origin, disability, age, sexual orientation. marital prosecution is completed, unless there is a status, or gender identity or expression. compelling reason for its retention; Services are funded through Palm Beach County Board of County Commissioners with grants from the Office of the O Have a Victim Advocate present during Attorney General and Florida Council Against Sexual Violence. depositions of the victim; like Us on 0 Request, for specific crimes, an exemption prohibiting the disclosure of information to the public which reveals your identification. Palm Beach County Board of County Commissioners PISCVIcUrrtServices N May 2015 EFTA00006057 Services Provided Sexual Assault Domestic Assault Professional butting and community Sexual Assault is a violent crime including rape, Domestic Assault involves power and control presentations are also available. incest, sexual harassment or any other sexual tactics such as physical violence. emotional abuse, contact without consent. sexual violence, economic abuse, and isolation. O. Information about Victims' rights Per Florida Statute 90.5035. a victim of sexual Victim Advocates Will Provide: violence who consults a sexual assault counselor at Crisis Intervention 4. 24-hour crisis response to hospitals, law a rape crisis center has the right to confidentiality of enforcement agencies and crime scenes information shared with the counselor. 4 Safety Planning No one except the victim can compel the sexual 0 Assistance with filing Restraining Orders 0 Sexual Assault Nurse Examiner (SANE) and a assault counselor to reveal information about their Forensic Exam site ti The Butterfly House 0 Safe-Shelter Referrals communications. Only the victim can waive the privilege, and this must be done in writing. 4 Sexual Assault Response Team (SART) 4 Personal and legal advocacy during to provide Victim-centered assistance If rape victims are not sure whether to report to law criminal justice proceedings enforcement, victim advocates will assist them through their decisionmaking process, respecting -4 Criminal Justice advocacy and whatever choices are made. court accompaniment Homicide and Certified Rape Crisis Victim Advocates Other Violent Crimes 4 Assistance with filing State Crime Will Provide: Victim Compensation applications and Homicide and other violent crimes shatter the 4 Crisis Intervention and Personal Advocacy lives of injured victims and survivors causing Restraining Orders Accompaniment during forensic rape exams at severe emotional trauma and grief. The Butterfly House and other medical facilities O Individual therapy and support groups Victim Advocates Will Provide: 0 Coordination of follow-up medical care, therapy and referrals 4 Crisis Intervention and emotional support 0 Information and referral to community resources, including shelters and Legal Aid 4 Criminal Justice advocacy and court accompaniment for victims and surviving family members 0 Assistance with filing crime victim Start by Believing: A Public compensation for medical expenses. Awareness Campaign to Change Start by MS, the Way We Respond to Sexual funeral costs and loss of support Believing Violence in Our Community... 4 Court Accompaniment one response at a time. Palm Beach County provides equality of services and 4 Referrals for individual therapy, support care to everyone, regardless of people's age, disability. YOUR REACTION MAKES THE DIFFERENCE. groups and community assistance gender, gender identity, race, religion or belief or When someone tells you they've been raped. there's a sexual orientation. simple response. Start by Believing. EFTA00006058 Help is Available Sexual Battery is a Crime! Forensic Exam Victims of sexual crimes need In Florida, the legal term for rape or What is a forensic exam? compassion, sensitivity and empathy. The forensic exam is a head-to-toe exam to collect sexual assault is sexual battery (F.S. evidence and check for injuries after a sexual crime. Being the victim of a crime can be 794.011). Sexual battery means oral, What are my rights with regard to the overwhelming. Your reactions are normal. anal, or vaginal penetration by, or union exam? Local certified rape crisis centers have with, the sexual organ of another or the • Stop the exam at any time advocates who are there to help all anal or vaginal penetration of another by • Have an advocate from a rape crisis center with you victims, regardless of whether or not any other object, committed without your • Be informed about the status of the kit during they report to law enforcement. consent. processing Services are free and confidential — What evidence is collected? Consent means Intelligent, knowing, certified rape crisis centers are legally During the exam, the medical professional may collect and ethically required to protect your and voluntary consent and does not blood, urine, saliva, pubic hair combings and/or nail include coerced submission. Failure to samples. They may also collect items of your clothing. confidentiality, unless you allow, in They will ask you questions about the crime and your writing, the release of your information. offer physical resistance to the medical history in order to help them collect evidence. Advocates are available to: offender does not imply consent. What happens to the evidence? • Provide crisis intervention If you make a report to law enforcement, your kit will A person under 16 years of age be sent to the regional or statewide lab within 30 • Speak to you on the 24-hour hotline cannot legally consent to sex. Also, a days for testing. The lab is required to process the kit • Discuss your options within 120 days. person 24 years of age or older or a • Navigate available resources If you don't report the crime to law enforcement at person in a familial or custodial the time you obtain the exam, your kit will be stored • Go with you to appointments position of authority cannot receive anonymously. Your kit may be stored for only a • Address safety concerns limited time, depending on your community's storage • Advocate on your behalf consent from 16 and 17 year old space. The local rape crisis center can advise you • Help you apply for victim compensation minors. about the storage timelines in your community. EFTA00006059 Victim Compensation Resources 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 You have the right to: You may be eligible for For TTY Accessibility: 1-877-414-7234 E-mail: sexpred@fdle.state.fl.us • Obtain a forensic exam whether or not you report financial assistance for: to law enforcement Florida Department of Corrections • Medical Care • Have an advocate at the forensic exam with you Victim Information and Notification Everyday • Have the forensic exam sent for testing within 30 • Lost Income (VINE) days, if reported to law enforcement 1-877-VINE-4-FL • Review the law enforcement report prior to final • Mental health services www.dc.state.fLus/othivictasst/index.html submission • Relocation • Be informed, present, and be heard at all crucial Florida Abuse Hotline stages of the criminal or juvenile proceeding • Other expenses related to injuries as a result 1-800-962-2873 • Have an advocate with you during a discovery of the crime deposition Local Rape Crisis Center • Have identifying information about the criminal Contact your local certified rape investigation kept confidential crisis center for more information. Palm Beach County Victim Services • Have the offender, if charged, tested for HIV and hepatitis & Certified Rape Crisis Center • Attend sentencing or disposition of the offender This project was supported by Grant • Notification of judicial proceedings and scheduling Victim Services SART Center No. 2015-WL-AX-0037 awarded by changes 4210 North Australian Avenue the Office on Violence Against Women, • Notification about the release of incarcerated offender U.S. Department of Justice. The West Palm Beach, FL 33407 • Request restitution opinions, findings, conclusions, and Office: 561-625-2568 • Give a victim impact statement recommendations expressed in this • Not be subjected to a polygraph Helpline: 866-891-RAPE (7273) publication are those of the author(s) • Take up to 3 days of leave from work (with eligible www.pbcgov.com/publicsafety/ and do not necessarily reflect the views employer) • Apply for an injunction if you fear for your safety or of the Department of Justice, Office on victimservices offender is nearing release Violence Against Women. AWN 2ol . 40:0 EFTA00006060 Center for Trauma Counseling 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.parrnbeachmentalhealth.org EFTA00006061 Office of the Attorney General The Capitol. PL-01 • Tallahassee, FL 3230-1050 . Office: (800)2264687 Fax: (853) 414.6191 at 1.803.9558771 Bill Status Inform:tier for Providers 050) 414-3331 • TDD users may call through Florida Relay Service 'Nebsite: myfloridalegal com • Email address: vointake@myfl oridalegal.com BUREAU OF VICTIM COMPENSATION CLAIM FORM Instructions (please print). attach all required Please read the Eligibility Requirements to see if you qualify for this program. Fill out this form completely documentation. and submit to the above address. I' you move or change your address. you are required to notify this office. CHECK THE TYPE Of VICTIM COMPENSATION BENEFITS YOU ARE REQUESTING: Fl DISABILITY - compensation for the victim who suffered a Donnell cisatilty. EXPENSES • payment cc retnticrsenent on oehSt of the victim for cnme-retaed I—I (Attach documentasn as cktined in Section 3.) funeral/burial, medical/dente treatment and mental health cornseing expenses: as well as aesoiptions, eyeglasses, dentures, ons prosthetic &Ake lost Eg WAGE LOSS - compensation fa the victm who lost wages due to crime related ph injuries (Math documentation as outlined in Section 3.) victim damaged, or required because of (Attach termed bels and receip FUNERAL/BURIA L cone. treatment/funeral EDICALMENTAL NTAL HEALTWGRIEF SS OF SUPPORT - compensation for the dependent(s) of a deceased O COUNSELING TREATMENT who was employed at the time of the crime. (Attach Cournentaticn as alined in Section 4.) in EMERGENCY ASSISTANCE - relmtursement fu dixturnented wage bee and out-of-packet a/pauses related b da Came. (Attach receipts.) CHECK ALL OTHER TYPES OF 8ENEFFS YOU ARE REOUESTNG: (Separate claim numbes we be assigned.) In PROPERTY LOSS for an Wuh over the age of 60 or enabled adult ,attach (- 1 DOMESTIC VIOLENCE RELOCATION ASSISTANCE - be the victim of proof disabity pre( to the dab) of nine from a physician a the Social Security donestc violence seeking assistance to relocate to a sate environment. A Administraton) who suflered the loss of tamable serSOna: property, as the restlt cerifieo domesic violence certiftalon form and applcaton nust be receved of a criminal or delinquent act. Math a receipt of written estinate train a vendor with 33 days horn the date of crime. or merchant identifying lie comparable replacement value. Compensabie items ri HUMAN TRAFFICKING RELOCATION ASSISTANCE - for the vctiir of sexual mist be identified by the law enforcement report traffickng with an urgent need to relocate. A rape orals or domestic ‘iolence In SEXUAL BATTERY RELOCATION ASSISTANCE - for the vctm of sexual certer cerbicaton fern and applicator] must be received within 45 days of the Celery seeking assstance b relocate due to reasonable fear A certified rape last identifiable threat. crisis center certificatior form must be received with Ine appintion. Section 1. Victim and Applicant Information VICTIM'S NAME (lar. Net mcldle) SOCIAL SECURITY NO. ADORE CCCUPATICe TELEPHONE NUMBER ALTERNATE PHONE NUMBER gala wv-ety.r.va,A- TITS INFORMATION IS COLLECTED FOR FEDERAL REPORTING PURPOSES AND IS OPTIONAL. O NATIVE HAWAIIAN or OTTER PACIFIC ISLANDER ❑ OTHER RACE RAMETHINICEY CIMAERICAN 'MAW EIASLAN BLACIVATRICAN rl HISPANIC cr I--IkLASKA NATIVE I—I AMERICAN L.—I LATINC WHITE NONLKINOCAUCASIAN O eiLLTIRE RACES GENDER: ti !it NATIONAL ORIGIN likS P1 WAS VICTIM DISABLED BEFORE THE CRIME OCCURRED? D YES adult victim prcol The applicant temp on peep* of a 'kern is required to provide clamant information below. When requestng compensation cn behalf of an incompetent of legal guardianship must be attached, and the applicant's signature an tie dairr form must oe witnessed by a Notary Public. IS THE VICTIM icheo ore) DECEASED O INJURED MINOR ❑ Al" WITNESS" NOT INJURED O INCOMPETENT APPLICANT NNE DATE OF BIRTH / Bed. first middle) / SOCIAL ' E-MAIL WOULD YOU UKE ALL CORRESPONDENCE YES NO SECURITY NO. I ADDRESS SENT BY EMAIL? ADDRESS CITY STATE ZIP CODE TELEPHosE / ALTERNATE i RELATIONSHIP OCCUPATION TAMER k PHONE NUMSER k TO vICTIM Page 1 of it EIVC lee Vt15) The Mee of the Attorney General. Bureau of Victim Compensation is an equal opportunity provider and empasyer. EFTA00006062 Section 2. Referral Source Information below. By signing this applicatior, the victim/applicant Individuals who assisted with or filled out any sections of this application are required to provide referral information is signed. (Treatment providers can request affirms that all information provided is true and correct, and thus. al sections should be reviewed before the application training on the Victim Compensation Program. which is recommended prior to becoming a referral source.) I EMAIL MME OF PERSON ASSISTING WITH APPLICATION ADDRESS past first mimic) hAME OF AGENCY/ORGANIZATION ELEPHQNE AGENCY ORGANZATIONS ADDRESS NUMBER (address. city, state, zip code) Section 3. Disability or Lost Wages Information tee d the CAM V)0ll ae Semple* Men westing ceneersatcrfor bst %vars.tech a copy ofyour ray stub or conics staterrynt atiich 'decrees you eTploinert stale WO wages ate mot than 5 work days were meted as a rasa d the crime Malta &dors bear or voider a trtiyrnenter,attach a spay of yet blest barna tax ream aril apckabe MS schedule tarns. If alath a dactyls letter neon speaks each cite related penmen( cisabity rang exoreIng bleanest:an lAeckal wtich erased you kr tag abseret When leclAstril dsatilY COMPenSaf011, AssoParn Gtitlekes ar Sktifia Imparrre7t Patric Gudekes. and favrad &oat SepolykInwasaatcr award leders SUPERVISOR'S WE ) NIJWEER TELENCINIE liAl.E OF COMPANY/BUSINESS le we ban ere In ernotiyar,pkeie mach looms 'heel CONPAINY ADDRESS Iaddress. city state, zip code) IS VICTIM DISABLED AS A RESULT OF THE CRIME? n YES I I NO IS WAGE LOSS COVERED BY INSURANCE? LI YES IS WAGE LOSS COVERED BY WORKER'S COMPENSATION? I-1"°YES n NO Section 4. Loss of Support Information or Grief Counseling Information attach a copy of the deceased victim's 'ndicate the narre(s) and date(s) of birth of the deceased viaim's surviving spouse, parent, s bang, or chid. For bss of support 3t•eSI income tar rein and individual earnings statement reemploynont assistance benefit statement. tour rimer for support. birth mrtficate which idenbfies dependent viationship, marriage cerhficato, or legal documentation proving principal suapidt. DEPENDANTAUNCR CLAINAN- NAME(S) DATE OF BIRTH RELATIONSHIP TO MTN Section 5. Insurance Information irsurance deductble or co-payment provisions Of Clements who are determined eligible for the Vctim Compensation and Prcoerty Loss Program may be 'mem( Iran the their insurance policyQes). IS INSURA.NCE OR MEDCAJD AVAILABLE TO ASSIST WITH THESE EXPENSES? O YES NO MEDICAID NUMBER Of Senses statardends). yes, prende be foaming ix d inwrance paces. including lAerliceid Medicare. Flo hanoonnoq. ailomobit, or moice medal &tad as related insdarce Expknabcn I TELEPHRONE/ 258- 5 i COMPANY NAME NUMBE 0 - 40 - 115 - AV-C (AM ilVt WAWA CITY ZIP ADDRESS CODE 2. COMPANY NAME POLICY NUMBER TELEPHONE/ NUMBER CITY STATE Zr ADDRESS CODE Section 6. Other Compensation, Settlement, and Attorney Information source as a result of this inadent. You must also You must notify this off ce if ye/ have race yea or f yrn antapate receiving compensation or any benefits from any tithe notify this office if you or have are laming to hire an attorney to represert you as a result of the incident STATE THE SOURCE AND I ARE YOU REPRESEN-ED_ / IATTORNEY'S NAME DATE RECEIVED (IFAPFUCAN1) I 0 I ‘S- t 41 BY LEGAL COUNSEL? L' S 0 EMAIL NO I ADDRESS ADDRESS CITY STATE ZIP I TELEPHONE \ CODE NUMBER and employe, Pogo 2 of 4 BY; 100 tits) The Office of the Attorney General, Bureau of Victim Compensation is an equal oeportoney provider EFTA00006063 Section 7. Crime Information to submit proof of crime wit result in ent report a charging affidavit) must be attached. Failure This section must be completed and proof of Crime (such as a law enforcem your application not being processed or your claim being denied. DATE OF I DATE REPORTED TO LAW NAME OF LAW CRIME ENFORCEMENT AGENCY ENFORCEMENT AGENCY ONO j YES WAS THE CRP& REPORTED TO LAW ENFORCEMENT WITHIN 72 HOURS?section will result in a denial of beneib.) on in this If no. please explain. (II no. failure to provide an acceptable explanati ❑ YES 13 NO ED WITHIN ONE YEAR FROM THE DATE OF CRIME? IS THE APPLICATION AND LAW ENFORCEMENT REPORT BEING SUBMITT one year from the date of crane. with sane exceptions for minor wan treatment losses suffered within If no, please explain. (Please be advised that most benefits apply to result n a denial of bonen.) II no. Mime to Monde an %Made explanation in this seams MI LAW ENFORCEMENT TYPE OF CRIME AS SPECIFIED REPORT NUMBER ON THE LAW ENFORCEMENT REPORT NAME OF OFFENDER NAME OF LAW Nlmoitin) ENFORCEMENT OFFICER STATE ATTORNEY! NME OF ASSISTANT STATE ATTORNEY CLEW OF COURT CASE NUMBER (if appicable) HANDLING THE CASE Of applicatle) Section 8. Eligibility Requirements apply. Additional qualification criteria. deadlines, and exceptions not listed may General's Office. The clime must coopera te fuly with law enforcement officials, State Attorneys Office, and the Attorney Victim Compensation (VC): The victim filed Within one year after the date is good cause for delayed reporting. The claim must be must be reported to law enforcement within 72 hours, unless there ents apply to victims who are minors. not fling within one year. Exceptions for filing time requirem of the crime or within two years when there is good reason for about his or her own injury or death. The victim must have ted to the situation that brought The victim must not have engaged in an unlawful activity or contribu as a result of the crime. suffered a physical, psychiatric, psychological injury, or death personal property as the result of a tial diminution in their quality of life from the loss of tangible Property Loss (PL): The victim must have suffered a substan $1,000 on all claims. $500 on any one claim and a lifetime maximum of criminal or delinquent act. Property loss reimbursement is available up to environment. The application must need immediate assistance to escape a domestic violence Domestic Violence Relocation Assistance (DV): The victim must the State of Florida is required. The victim must tion by a certified domestic violence center in be filed within 30 days after the domestic violence crime. Certifica service, transporta tion, moving company expenses, or deposits, new cellular phone submit estimates, invoices, or receipts for interim lodging, housing, utility emergency food or clothing. Certification by a certified rape need to relocate due to a reasonable fear for his or her safety. Relocation for Victims of Sexual Battery (RS): The victim must housing , utility deposits, new cellular submit estimates, invoices, or receipts for interim lodging, crisis center in the State of Florida is required. The victim must emergency food or clothing. phone service. transportation, moving company expenses, or ent directly related to a sexual human must have an urgent need to escape from an unsafe environm Human Trafficking Relocation Assistance (HT): The victim identifiable threat must have last identifiable threat by a human trafficking offender. The trafficking offense. Application must be received within 45 days of the is required. The victim rape crisis or domestic violence center in the State of Florida been communicated with the proper authorities. Certification from a certified transpo rtation, moving company expenses, housing, utility deposits, new cellular phone service, must submit estimates, invoices or receipts from interim lodging, or emergency food or clothing. in custody in a county considered, the victim or applicant must not have been confined or Criminal History Record Check: In order for compensation to be l felony offender. n commitment. Or assessment facility; adjudicated as habitua a a municipal facility; a state or federal correctional facility; or a juvenile detentio a forcible felony offense. habitual violent offender, or violent career criminal; or adjudicated of , but only after all other sources of sation may provide financial assistance for eligible persons Notice of Payment Limitations: The Bureau of Victim Compen red paymen t-in -full per Florida Statute. Total victim providers on behalf of victims are conside . payment have been exhausted. Payments accepted by in-state the maximum may ipty to determined by the current benefit payment schedule. Limits below compensation benefits cannot exceed the maximum award amount recipient based on the availability of funding. specific benefits, which may be reduced without prior notice to the award sable crime occurred, but does not make an independent judgment on whether a compen Acceptable Proof of Crime: The Bureau of Victim Compensation a compen sable crime occurred shall result to provide acceptable documentation proving that instead relies on proof of crime from the proper authorities. Failure : a enforce ment report or charging affidavit from ble documentation includes law in your application not being processed or your claim being denied. Accepta that affirms a compen sable crime ting attorney. or the Department of Children and Families a child protection team, law enforcement agency, state or prosecu the United States Federal Bureau of tor from a court of competent jurisdiction; a report from occurred; an indictment by a grand jury; an indictment by a prosecu for purpose s of Section 960.197 , F.S. investigator certification of a crime Investigation; or a Florida Department of Law Enforcement cybercrime ble documentation proving that a provide a complete application package which includes accepta Complete Application Package: It is your responsibility to ion will be assigned a claim ent for proving that a compensable crime occurred, the applicat come occurred. If the department receives a report which is insuffici g accepta ble docume ntation. please contact e of eligibility or denial. For assistance with collectin number and denied. Claim numbers assigned are not indicativ or your local State Attomey 's Office. was reported, the referral source, your local law enforcement agency, the agency where the crime an equal opportunity provider and employer. Page 3 of 4 BVC 100 (7/15) The Office of the Attorney General, Bureau of Victim Compensation is EFTA00006064 PLEASE READ CAREFULLY AND SIGN THE FOLLOWING CERTIFICATIONS Section 9. harassment, aggravated battery, or domestic CONFIDENTIALITY: If you are Ire victim of a sexual battery. aggravated chid abuse. aggravated stalking, information about your home address and telephore number, employment address and telephone number, and your violence. you have the rignt to have you are the victim of any of these crimes, please mark one of the following statements. Your personal assets, kept confidential for a period of five years. If response will not affe the processing of your claim. I want the information to be confidential O I do NOT want the information to be confidential of crime-related expenses that cannot be paid by any other SERIOUS FINANCIAL HARDSHIP: I certify that I have a senous financial hardship because source. that this loss adversely affects the victim's quality of life: PROPERTY LOSS CERTIFICATION: I eerily that the property in question belonged to the victim: that replacement of the prope-ty would cause the claimant a serious financial hardship. that there is no other source of reimbursement for this loss; and counselor, or other treatment provider, bankng triStrtution, RELEASE OF INFORMATION: I give permission to any hospital, doctor. dentist, mental health agency, state attorney's office, inssance carrier, attorney or employer to give out information that social service agency, law enforcement agency. corrections payer, or law enforcement nvestigative information to the Department is requested concerning any treatment rendered, employment Insurance thrd-party for use in processing my dom. I give permission lo the Department to release information about the status of my claim to any treatment of Legal Affairs provider, law enforcement agency. or state attorney's office. Security numbers for the purpose of performing SOCIAL SECURITY NUMBER DISCLOSURE: The Bureau cf Victim Compensation collects and uses Social the forowing: searching criminal history records. identity management. biting and payments, benefit mperatve duties and responsiNifieswtoch may include Failure to provide this optimal information may delay lhe processing of your processing. and reporting to authorized state and federal government agencies. parties. Absent a waiver numbers from disclosure to ulauthoized application or benefits. Federal and State laws fracture the Bureau to protect Social Security legal representative Social Security numbers will be redacted. unless the agency receives a court order to turn over a ron redacted file. from you or your is a payment of last resort and that I must repay the Crimes REPAYMENT REQUIREMENT: I understand that payment by the victim compensation program Compensation Trust Fund if I receive a victim compensation award and also receive payment from another source as a result of the same crrninal incident Otter sources include. but are not limited to, any payment from the offender an insurance policy. a settlement, a judgment or an award in a third party lawsuit. Compensation Trust Fund, If my claim is determined ineligible. I also understand I further understard that I must repay any emergency award from the Cnmes received from the Crimes Compensation Trust Fund. that if my eligibility is withdrawn, I must repay any amount a vctirts estate. APPLICANT: Applcant signature is required if Mine as the parent. legal guardian. a individual authorized to administer Pnnted Name: Signature: Date. best o' my knowledge. Under Penalty of Perjury or fraud, the information I have provided is true and correct to the prin.,' or legal guarcianship NOTARIZATION REQUIREMENT: Persons submitting an application on behalf of an incompetent adult must sibmit and have their signalize mtnessed by a Notary Public. Sworn to and subscribed oefore nit this day of . 20 Personalty known to me. Identification produced. Votary Pottle Signature: Stamp/Seal: Page 4 of 4 BVC 10i (-7/15) The Office or the Attorney General, Bureau of Victim Compensation is en equal opportunity provider rid employer EFTA00006065