Victim/Survivor Intake Form
This form 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. All information will be kept confidential. If you need assistance filling out this form, please call us at 706-842-8467.
Nuestro formulario para asistencia financiera de emergencia está disponible en español. Póngase en contacto con nosotros en firstname.lastname@example.org para obtener ayuda.
Section I: Victim Information
Full Name (First Name, Middle Initial, and Last Name):
Section II: Victim's Circumstances
Please state the mass casualty crime, relationship (self/survivor, mother, father, etc.), and circumstances of financial hardship. Be sure to include the name and phone number of your victim advocate for verification (if applicable):
Section III: Supporting Documentation
Attach proof of financial hardship (ex: late notice(s), medical bills, utility bills, etc.). If you do not have a PDF or digital document, you may submit clear photos of the documents using the "Upload Photo" buttons. Please make sure that account numbers and payment information is clearly visible so we can submit payment (if/when approved). Photo ID will also be needed to verify your identity. If request is for housing (rent/mortgage assistance), a utility bill, lease agreement, or proof of address is also required. Additional documentation can be sent via email to email@example.com.
Total amount of emergency financial assistance requested (please make sure this amount is supported by the documentation provided):
Section IV: Transfer of Funds
If your request for emergency financial assistance is approved by the Board of VictimsFirst, please select how you would like funds to be transferred to you. Rents, utilities, and similar bills are typically paid directly to the account and not to individual applicants.
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 Board. 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.