This form is to be used only by the legal heir/trustee of the family of the deceased and the wounded survivors of the mass shooting that took place at the Allen, TX Outlet Mall on May 6, 2023.
Information provided will be kept confidential.
Survivors can skip Section III.
Applicants for deceased victims must fill out all sections.
If you need assistance filling out this form, please call us at 706-842-8467.
Section I: Form Information
Full Name (First Name, Middle Initial, and Last Name):
Section II: Photo ID
Upload a valid photo ID to verify your identity. If you do not have a valid photo ID, please email us at firstname.lastname@example.org.
Section III: Victim Information
Victim's Full Name:
Victim's Date of Birth:
What is your relationship to the deceased?
At the time of death, what was the deceased's marital status?
Did the deceased victim have a will? If so, please upload.
If the deceased victim was under the age of 18, are the victim's parents still married to each other?
Is the victims' Mother alive?
Is the victims' Father alive?
Section IV: Beneficiary Information
Full Name of Legal Beneficiary:
Does the beneficiary receive government assistance?
Does the beneficiary have a U.S. bank account?
Does the beneficiary want to receive the gift by Zelle or check?
If Zelle, please provide phone or email used for beneficiary's Zelle account:
If check, please provide the full mailing address of the beneficiary:
Section V: Signature of Claimant
By signing below (e-signature), I hereby certify, under penalty of perjury, that the information provided in this application is true and accurate to the best of my knowledge. I further state that the information provided did not originate with fraudulent intent by me or any person acting in concert with me and that the signature below is my own legal signature. I give VictimsFirst permission to contact accounts and account administrators to verify that the information I provided is true and accurate. Lastly, I acknowledge that the benefits paid by the fund are a gift to which no person has a legal claim or entitlement.
Your application has been submitted!