Apply for Emergency Financial Assistance
This application is to be used only by immediate family members of the deceased, those wounded/injured, or who have survived a mass casualty crime to request emergency financial assistance from VictimsFirst's National Mass Shooting Victim's Fund.
This Fund is available to help with the immediate, mid-term, and long-term needs of victims of mass casualty crime.
Information provided will be kept confidential.
If you need assistance filling out this form, please call us at 706-842-8467.
Applications will be reviewed and processed by our Committee in the order they are received. Funds are limited and are dependent upon donations to VictimsFirst.
Nuestro formulario para asistencia financiera de emergencia está disponible en español. Póngase en contacto con nosotros en email@example.com para obtener ayuda.
Section I: Victim Information
Full Name (First Name, Middle Initial, and Last Name):
Section II: Victim's Circumstances
Please provide the following information:
(1) Name/Location of the mass casualty crime (i.e. Robb Elementary School Shooting in Uvalde, Tx)
(2) Relationship (i.e. self/survivor, parent of a murdered victim, etc.)
(3) Brief description of the financial need (i.e. co-pay for medical bills resulting from injury, food, rental assistance while I am recovering, etc.)
(4) Name and phone number of your victim advocate for verification (if applicable)
(5) Please let us know if you receive income-based state/federal aid not related to this incident so we can make sure you retain your eligibility (if applicable)
Section III: Supporting Documentation
(1). Provide a valid photo ID. This is used only to verify your identity. If you do not have a valid photo ID, please email us at firstname.lastname@example.org. We can also verify your identity through your victim advocate.
(2) Optional: Documentation of financial need (i.e. utility bill, car repair estimate, rental agreement/lease, etc.). Additional documentation can be sent via email to email@example.com.
Total amount of emergency financial assistance requested:
Section IV: Transfer of Funds
Select the preferred method of payment:
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. Lastly, I give VictimsFirst permission to contact accounts and account administrators to verify that the information I provided is true and accurate.
All requests for emergency financial assistance are reviewed by the National Mass Shooting Fund Committee. We cannot pay personal legal fees or provide financial assistance during bankruptcy proceedings. We may ask for additional documentation for verification purposes (if needed). We will reach out to you within 48 hours with the Board's decision. If you do not hear from us within 48 hours of your submission, please reach out to us by emailing us at firstname.lastname@example.org or by calling us at 706-VICTIMS.