EFTA01699895

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 EFTA01699895 Have You Been ces Provided . 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 Da You 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 call. O Play Therapy * Feeling anxious or depressed? Therapists are available for appointments O Assistance for parents during this * Having outbursts of anger? Monday through Friday, excluding legal difficult time * Inability to concentrate? holidays. * Feeling emotionally numb? Signs Of 'Mama In Children Therapists Will Help You: * Loss of interest in the things yourpsed 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? • 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 OMNI l'Af' irritable. The child may lash out in anger ;PC Palm Beach County provides equality of services and O Experience a reduction of trauma symptoms O Return to work or school resulting from the distress he/she is feeling. O Regression: The child may revert to acting care to everyone, regardless of peoples age, disability, like a baby. bedwetting, clinging and O Explore the impact on current and future gender, gender identity, race, religion or belief or relationships demanding extra care. sexual orientation. EFTA01699896 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 EFTA01699897 Services Provided Sexual Assault Domestic Assault Professional training 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. * 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 <> 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. Safety Planning No one except the victim can compel the sexual 4 Assistance with filing Restraining Orders 4 Sexual Assault Nurse Examiner (SANE) and a assault counselor to reveal information about their Forensic Exam site a, The Butterfly House Safe-Shelter Referrals communications. Only the victim can waive the privilege, and this must be done in writing. 4 Sexual Assault Response Team (SART) a, 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 court accompaniment whatever choices are made. 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 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 0 Individual therapy and support groups Victim Advocates Will Provide: 4 Coordination of follow-up medical care, therapy and referrals 4 Crisis Intervention and emotional support 4 Information and referral to community resources, including shelters and Legal Aid 4 Criminal Justice advocacy and court accompaniment for victims and surviving family members Assistance with filing crime victim Start by Believing: A Public compensation for medical expenses, Start by Iss -- Awareness Campaign to Change 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. EFTA01699898 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. EFTA01699899 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 EFTA01699900 Center. for Trauma Counseling Where Your Emotional Healing Can Segin 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 EFTA01699901 Office of the Attorney General The Capitol. PL-01 • Tallahassee, FL 32399-1050 • Office! (800) 226-6657 Fax: (850) 414-6191 Service at 1.803-955.8771 Bill Status Information for Providers 1850) 414-3331 • TOD users may call through Florida Relay Website: myfloridategal.com • Email address: vcintake@myfl oridalegal.com BUREAU OF VICTIM COMPENSATION CLAIM FORM Instructions completely (please print). attach all requred Please read the Eligibility Requirements tc see if you qualify for this program. Fill out this form documentation. and submit to the above addross. If you move or change your address. you are required to notify this office. CHECK THE TYPE OF VICTIM COMPENSATION BENEFITS YOU ARE REQUESTING: I—I DISABILITY - compensation for tie victim who suffered a permanent disability. EXPENSES - payment a reimbursement on *mil of the victm for cnme-retared / I—I (Attach documentation as outlined in Section 3.) WAGE LOSS - compensation for the victm who lost wages due to crime related ICJ funeral-burial. medicaPdental treatment and mental heath comsehng expenses: as well as prespiptions, eyeglasses, dentures, or a prosthetic deice lost damaged, r required because i of wi crime. ph sal Injuries (Attach documentation as outlined in Section 3.) (Attach tamed his and mei freatmentluneral or idea.) victim FUNERAUBURIA L e Z EDICAUDEN-AL NTAL HEALTH/GRIEF SS OF SUPPORT - compensation for the dependent(s) of a deceased TREATMENT COUNSELING who was employed at the time of the crime. Attach decunentatico as outlined in Section 4.) In EMERGENCY ASSISTANCE • reimbursement ty documented wage loss and l---I out-of-packet expenses related lo the aims. Attach motets i CHECK ALL OTHER TYPES OF BENEFITS YOU ARE REQUESTING: (Separate claim numbers MI be assqred.) ri PROPERTY LOSS for an *dull over the age of DO adisableddieadult !attach ri DOMESTIC VIOLENCE RELOCATION ASSISTANCE - by the victim of Security proof o' disability prow to the dale of crime from a physician or Social domestc violen:e seeking assistance to relocate to a sate ervironment A Administraton) who sufered the loss of tang ble "mom; property as the result cease domestic violence certification farm and applcaton must be receved of a criminal or delinquent act. Mach a receipt or written estimate from a venter within 33 days from the date of cnme. or merchant identifying tie comparable replacement value. Compensable items CI HUMAN TRAFFICKING RELOCATION ASSISTANCE • 'or the victim of sexual must be idenfiGed by the le* enforcement report trending with an urgent need to relocate. A raps cats or dynastic violence El SEXUAL BATTERY RELOCATION ASSISTANCE • tor the vCOM of sexual center cervicaton form and apckaton must be received within 45 days of the " battery seating assatance b repeat des to reasonable tear A certified rape last identifiable threat crisis center certification form must to received wAh he application. Section 1. Victim and Applicant Information VICTIM'S NAME DATE0 MTN Oat fait, middle) SOCIAL SECURITY NO. ULD YOU MEAL.CCRRESPCNDENCE NT BY EMAIL? ISSYES El NO TY STATE ADORE oath Pc..kmfSecAch ft— cote 35401 TELEPHONE ALTERNATE OCCUPATION PHONE NUMBER it( ‘a.a cAL eh NUMBER INS INFORMATION IS COLLECTED FOR FEDERAL REPORTING PURPOSES AND IS OPTIONAL FLAMETHINICrY: rIAMERICAN WM ❑ASIAN I—I 8LACKA HISPANIC 0 O NATIVE HAWAIIAN°. ODER PACIFICISLANDER ❑ OTNERRACE P ❑ MULTIPLE RACES Fec, "ALASKANATIVE L--IAMEHRAN ICAN❑ LJ LANNC eWHITENOIELKINOCAVCASIAN GENDER ine NATIONAL ORIGIN LAS WAS VCTIN DISABLED BEFORE THE CRIME OCCURRED? ❑ YES Elm) incompetent adult victim, proof The applicant filing on behalf cf a victim is required to pretide claimant information below. When recNeStng compensation cn behat of an must be witnessed by a Notary Public. of legal guardianship must be attached, and the applicants signature on the claim form IS THE WOW Idea one) O DECEASED ❑ INJURED MINOR I—I AIINCR WITNESS- NOT IN.AIRED ❑ i4COLIESTEVI APPLICANT NAME DATE OF MTH / / (last first ?riddle) SOCIAL Emil WOULD YOU LIKE ALL CORRESPONDENCE ❑ YES ❑ NO SECURfRY NO. ADDRESS SENT BY EMAIL? ADDRESS CITY STATE ZIP CODE TE.EPHONE ) ALTERNATE i ) RELATIONSHIP OCCUPATION NUNIRFR ( PHCNE NUV3ER k TO VICTIM Page 1 of 4 BVC 100 (ma) TN Office of flue ArThrney Ganaral. Bureau of Victim Comperestion is an equal opportunity provider end employer. EFTA01699902 Section 2. Referral Source Information By siring this apolicatior, the victim/applicant IndividuaS w41O assisted with or Stied out any sections of this application we required to provide referral information below. correct and thus, all sections should be reviewed before the application is signed. (Treatment providers can request affirms Vat el informaticn provided is true and training on the Vctim Compensation Program. which is recommended prior to becoming a refaral source.) E-MAIL NAME OF PERSON ASSISTING WITH APPLICATION pest fast middle) ADDRESS MME OF AGENCWORGANIZATICN TELEPHONE AGENCY.ORGANIZARONS ADDRESS NUM3ER !_address. Qty. stalk rip code) Section 3. Disability or Lost Wages Information Ire of Iheoime. lyou aeselfenployed When respestng conigensaden brbst wages.adath a cm of you' pay stub cc awnings statement whthdentifies youemployment slats at woes at the missal as a retold te &ere aladiadooter's better cr wok fa a fariy member, attach a cep/ of your blest income tax ram and amicable IRS scteduie tires. I more than Swart dais was a dada's Neer Mich species ea& thme tad pamment disabity rating axoning b reAmerica-I Medcar which exasee you for tae ateerce.Men reliesthg deabitycompereatn. adapt Assoiaim Giideines Ebriga Irrpliment Ring GAM% affected Social Scarily Admrestator award letters TELEPHONE ) SUPERVISOR'S NAIIE NJMEER RAW OF COMPANY/BUSINESS el we sun ere Illemptier.pima emch wagons sheen COWART ADDRESS ieuiress, Oty, crab. Bp code) IS VICTIM DISABLED AS A RESULT OF THE CFdME7 YES 11 NO S WAGE LOSS COVERED BY INSURANCE? LI YES NO S VtAGE LOSS COVERED BY WORKER'S COMPENSATION? YES n NO Section 4. Loss of Support Information or Grief Counseling Information anach a cop/ of the deceased vitro's Micate the narrets'd and date(s) of both of the deceasec victro's surviving spouse, parent. s toting, 0' chid. For loss of support tail certficae which deities dependent :Meet income tax return and individual earnings statement reemployment assistance benefit statement cour, orcer for support, elation-ship, manage certificate or legal documentation proving princi,pa support DATE OF BIRTH RELATIONSHIP TO viCTLi DEPENDANT/MINCR CLAMANT NAME(S) Section 5. Insurance Information deductible or co-payment provisions of Clements who are determined eligible for the Vaim Compensation and Rooerty Loss Programs may be exempt him the insurance their insurance oolicy(ies). IS INSURANCE OR MEDOND AVAILABLE TOASSIST WITH THESE MENSES? O YES ID NO MEDICAID NUMBER: &planation of )melt. sistcment(5). It yes. promo ow Mimeos or al mumse pokier. ock(Ong Idedcaid Medan, He. horiecvinces. (Amebic, ormajor nrdinl Arach ell related instate t. TELEPHONE/ _ 09 KAMER {I . - '1l S. 2 s t 5 CO"ANir: (fit% bfi- h•C tka CITY ZIP ADDRESS CODE 2. COWANY NAME POLICY NUMBER TELEPHONE( NUMBER k CITY STATE ZIP ADDRESS CODE Section 6. Other Compensation, Settlement and Attorney Information source as a result of this hitident You must also You must notify this office if you have race vect or 1you anticipate receiving compensation or any benefits from any other notify this office if you have or are planning to lire an attorney to represent you as a result of the ncident STATE THE SOURCE AND I ME YOU REPRESENTED ATTORNEYS DATE RECEIVED (IF APPJCABLE) kOk i t al BY LEGAL COJNSEL? AEso S O NO ADDRESS EMAIL ADDRESS CITY STATE ZIP 1 TELEPHONE CCOE NUMBER Page 2 of BV: 1CO (7,15) The Off‘o cf the Attdroty Goners!, Bureau of Victim Compensation is an OqUal opportunity provider and empopy. EFTA01699903 Section 7. Crime Information proof of crime wit result in report or charging affidavit) must be attached Failure to submit This section must be completed and proof of crime (such as a law enforcement your application not being processed or your claim being denied. DATE CF I DATE REPORTED TO LAW NAME OF LAW CRIME I ENFORCEMENT AGENCY ENFORCEMENT AGENCY ❑ NO WAS THE CRIME REPORTED TO LAW ENFORCEMENT WITHIN 72 HOURS? ❑YES this sedan wia result in a (rental of benefits.) If no. please explain. DI no. fates to provide an acceptable exolanaton in YES ❑ NO SUBMITTED WITHIN ONE YEAR FROM THE DATE Cf CRIME? El IS THE APPUCATIONAND LAW ENFORCEMENT REPORT BEING from the date of crime. win some exceptions for mina Saint treatment losses suffered watts one year If no. please explain (Passes be advised that most benefits apply to result steamed of benefits.) If no, failure to provide an acceptable explanation in this sector wi LAW ENFORCEMENT TYPE OF CRIME AS SPECFIED REPORT NUMBER ON THE LAW ENFORCEMENT REPORT NAME OF OFFENDER NAME OF LAW (if kern) ENFORCEMENT OFFICER STATE ATTORNEY/ NAME OF ASSISTANT STATE ATTORNEY CLERK OF COURT CASE NUMBER (rf appkable) HANDLING THE CASE (d apflcSe) Section 8. Eligibility Requirements apply. Addifional qua cation criteria, deadlines. and exceptions not listed may Generals Office. The crime must coopera te fury with law enforcement officials, State Attorneys Office, and the Attorney Victim Compensation (VC): The victim year after the date cause for delayed reporting. The claim must be filed within one must be reported to law enforcement within 72 hours, unless there is good apply to victims who are minors. not filing within one year. Exceptions for filing time requirements of the crime or within two years when there is good reason for his or her own injury or death. The victim must have situation that brought about The victim must not have engaged in an unlawful activity or contributed to the of the crime. suffered a physical, psychiatric, psychological injury, or death as a result l property as the result of a tial diminution in their quality of life from the loss of tangible persona Property Loss (PL): The victim must have suffered a substan on all claims. to $500 on any one claim and a lifetime maximum of 51,000 criminal or delinquent act. Property loss reimbursement is available up environment. The application must must need immediate assistance to escape a domestic violence Domestic Violence Relocation Assistance (DV): The victim of Florida is required. The victim must tion by a certified domestic violence center in the State be filed within 30 days after the domestic violence crime. Certifica service, transpor tation, 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 , utility deposits, new cellular submit estimates, invoices, or receipts for interim lodging, housing crisis center in the State of Florida is required. The victim must emergency food or clothing. phone service, transportation, moving company expenses, or related to a sexual human have an urgent need to escape from an unsafe environment directly Human Trafficking Relocation Assistance (HT): The victim must a human traffickin g offender . The identifia ble threat must have last identifiable threat by trafficking offense. Application must be received within 45 days of the of Florida is required. The victim a certified rape crisis or domestic violence center in the State been communicated with the proper authorities. Certification from rtation, moving company expenses, , utility deposits, new cellular phone service, transpo must submit estimates, invoices or receipts from interim lodging, housing or emergency food or clothing. in a county red, the victim or applicant must not have been confined or in custody Criminal History Record Check: In order for compensation to be COnside or assessm ent facility; adjudica ted as a habitua l felony offender, juvenile detention commitm ent, or municipal facility; a state or federal correctional facility; or a a forcible felony offense. habitual violent offender, or violent career criminal; or adjudicated of after all other sources of provide financial assistance for eligible persons, but only Notice of Payment Limitations: The Bureau of Victim Compensation may paymen t-in-full per Florida Statute. Total victim providers on behalf of victims are considered payment have been exhausted. Payments accepted by in-state paymen t schedul e. Limits below the maximum may apply to determined by the current benefit 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 crime occurred, but does not make an independent judgment on whether a compensable Acceptable Proof of Crime: The Bureau of Victim Compensation sable crime occurred shall result acceptable documentation proving that a compen instead relies on proof of crime from the proper authorities. Failure to provide enforce ment report or charging affidavit from ble documentation includes: a law in your application not being processed or your claim being denied. Accepta of Children and Families that affirms a compen sable crime ting attorney, or the Departrn ent a chid protection team, law enforcement agency, state or prosecu States Federal Bureau of tor from a court of competent jurisdiction; a report from the United occurred; an indictment by a grand jury; an indictment by a prosecu s of Section 960.197 , F.S. rne investigator certification of a crime for purpose Investigation; or a Florida Department of Law Enforcement cybercri ntation proving that a a complete application package which includes acceptable docume Complete Application Package: It is your responsibility to provide a compen sable crime occurre d, the applicat ion will be assigned a claim ent for proving that crime occurred. If the department receives a report which is insuffici ntation. please contact denied. Claim number s assigne d are not indicativ e of eligibilit y or denial For assistance with collecting acceptable docume number and State Attorney 's Office. reported, the referral source, or your local your local law enforcement agency. the agency where the crime was Page 3 of 4 is an equal opportunity provider and employer. BVC 100 (7115) The Office of the Attorney General, Bureau of Victim Compensation EFTA01699904 PLEASE READ CAREFULLY AND SIGN THE FOLLOWING CERTIFICATIONS Section 9. harassment aggravated tatteiy, or domestic CONFIDENTIALITY: If you we the victim of a sexual battery, aggravated child abuse, aggravated stalking, to have information about your home address and telephone number, employment address and telephone number, and your violence. you have the right 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 you response will not affeft the processing of your claim. I want the information to be confidential El I do NOT want the information to be confidential expenses that cannot be paid by any other SERIOUS FINANCIAL HARDSHIP: I credit/ that I have a serous financal hardship because of crime-related source. loss adversely affects the victim's quality of lire: PROPERTY LOSS CERTIFICATION: I cerify that the property in question belonged to the victim: that this that replacement of the property would cause the claimant a serious financial hardship. that thee is no other source of reimbursement 'or this 'oss: and or other treatment 0rovider, bankng institution. RELEASE OF INFORMATION: I give permission to any nospital, doctor. dentist, mental health counselor, agency, state attorney's office, insurance earner, attorney or employer to give out information that social service agency, law enforcement agenCy. COyections payer, or law enforcement investigative information to the Department is requested concerning any treatment rendered, employment insurance. third-party for use in processing my claim. I give permission to the Department to release information about the status of my claim to any treatment of Legal Affairs provider, law enforcement agent/. or state attorneys office. numbers for the purpose of performing SOCIAL SECURITY NUMBER DISCLOSURE: The Bureau of Victim Compensation collects and uses Social Security the following: searching criminal history records, identity management, billing and payMents, benefit mperatve duties and 'esponsibilities which may include information may delay me processing of your processing and reporting to authorized state and federal government agencies. Failure to provide this optional unauthorized parties. Absent a waiver application or benefits. Federal and State laws require the 3ureau to protect Social Seventy numbers from disclosure to Social Security numbers will be redacted. unless the agency receives a court order to turn over a ron redacted file. from you or your legal representative. of last resort and that I must repay the Crimes REPAYMENT REQUIREMENT: I understand that payment by the victim compensation program is a payment Compensation Trust Fund if I receive a victim compensation award and alto receive payment from another source as a result of the same criminal Incident offender. an insurance policy, a settlement a judgment or an award in a third party lawsuit. Other sources Include. but are not limited to. any payment from the Trust Fund, if my claim is determined ineligible. I also understand I further understand that I must repay any emergency award from the Crmes Compensation Nom the Crimes Compensation Trust Fund. that if my eligibility is withdrawn, I must repay any amount received APPLICANT: Appicant signature is required if fling as the parent. legal guardian, or individual authorized to administer a vctlri's estate. Pnnted Name: Signature: Date: Under penalty of perjury or fraud, the irlormation I have provided is true and correct to the best of my knowledge. guarcianship NOTARIZATION REQUIREMENT: Persons submitting an application on behatt of an ncompetern adult must submit prod of legal and have their signature witnessed ty a Notary Public. Sworn to and subscribed Defore me this day of . 20 Personally known to me. O Identification produced. Notary Public Signature: Stamp/Seal: Page a of 4 BYC 100 (7/15) The Office of the Attorney Central, Bureau of Victim Compensation is en n04 opponuniy provider and employer EFTA01699905