Vision [EFTA00006055]

Vision \nJustice for all crime victims. \nMission Statement \nWith compassion and respect, \nwe assist victims of sexual \nevil- et, domestic violence, \nhomicide, and other violent \ncrimes through crisis response, \nadvocacy, therapy, and \ncommunity awareness. \nPalm Beach County \nVictim Services \nis a Certified Rape Crisis Center \nthat provides therapy services to \nall crime victims in Palm Beach \nCounty regardless of the victims' \nrace, sex, color, religion, national \norigin, disability, sexual \norientation, marital status, \nfamilial status or gender identity \nor expression. \nStart by Believing: \nStart by \nr \nA Public Awareness \nBelieving \nCampaign to \nChange the Way \nWe Respond to Sexual Violence in Our \nCommunity... one response at a time. \nYOUR REACTION \nMAKES THE DIFFERENCE. \nWhen someone tells you they've \nbeen raped. there's a simple response. \nStart by Believing. \nkilo. \nit . tr.; \ncounty \nSafety .Department \njiiiedin Services Division\nwwwpbcgov.com/publitsafety/victimSeeVicett \n24/7 SEXUAL ASSAULT \nVIOLENT CRIME HELPLINE \nHELPLINE: (561 -8$3`7273 \nTOLL FREE: (866) 891.7273 \n1:.N \nEoi rehouse \n-'205 45itil Utile Hwy , Suite 5.1109 \nWest Palm Beach. FL 33401 \n(561) 355-2418 option 3 \nTTY: (561) 233-2595 \nVictim Services SART Center \n42113 North Australian Ave. \nVilest Palm Beach. FL 33407 \n(561)625.2568 option 1 \n• \nTIT (561) 6244520 \nNoith County Courthouse \n3188 PGA Blvd.. Suite 1436 \nPalm Beach Gardens, FL 33410: \n(561) 355-2418 option 3 \n' \n(561) 624.6643 \nSouth County Courthouse \n200. West lykraje Ave., Suitt E-301 \nDenyW4aeh. \n(50) 274:1500 \nITV: (561) 274-1015 \nes" \nWest County-Glades Courthouse \n2976 $tate n&d 15. 2nd Floor \nBelle Glade, FL 33430 \n(561) 996-4871 \nITV; (561)992-1113.._ -.-\n--Like Us on \nprzvictimsgrytces \nSart-gifts are funded through Palm Beachtounty Board of \nCounty Cornthissioners with grants fronithe OKI& of the - \nAttorpeyGeneral and Honda Council Against Sexual Violence;;.,-. \n-0, \nPalm tescItCounly \nN\nPalm Beach \nti \n• '. \n'Public Saki< Denali Intent \niclim Sci viucs Di% is io \nSewing Victims of Violent Crimes \n1 \nEFTA00006055\n\nHave You Been \n,. \nA Victim Of A Crime? \nDo' Thu Experience \nAny Of The Following? \n* Inability to fall orstay asleep? \n* Feeling anxious or depressed? \n* Having outbursts of anger? \n* Inability to concentrate? \n* reeling emotionally numb? \n* Loss of interest in the things you used to enjoy? \n* Painful memories of the traumatic event? \n* Bad dreams about the traumatic event? \n* flashbacks or a sense of reliving the events? \n* Racing thoughts? \n* Physiological stress response to reminders of the \nevent? (pounding heart, rapid breathing, nausea, \nmuscle tension, sweating) \nPalm Beach County provides equality of services and \ncare to everyone, regardless of people's age, disability. \ngender. gender identity, race, religion or belief or \nsexual orientation. \nFree services include individual therapy \nfor children and adults and adult-support \ngroups. \nIf you are a crime victim or have been \na victim of crime in the past and are \nconsidering therapy, we welcome your coll. \nTherapists are available for appointments \nMonday through Friday, excluding legal \nholidays. \nTherapists Will Help You: \nO Identify trauma reactions \nO Explore the impact that trauma has on your daily life \nO Reduce the intensity of negative emotional \nresponses and symptoms \nO Learn about common trauma reactions and \nphases in healing \nO Feel hopeful and positive regarding the future \nO Develop coping mechanisms to utilize when \nthinking or talking about the crime \nO Experience a reduction of trauma symptoms \nO Return to work or school \nO Explore the impact on current and future \nrelationships \nerapy For \nChildren & Teenagers \nO Assessment and treatment for child victims \nof crime\nO Therapeutic interventions that teach \nchild safety \n• \n.0 Play Therapy \n.0 Assistance for parents during this \ndifficult time \nSigns Of lPauma In Children \nO Sadness: The child may feel despondent or \nhopeless The child may cry easily or withdraw/ \nisolate from others. \nO Loss of interest in activities: The child may \ncomplain of feeling "bored" or reject offers to \nparticipate in activities they have previously \nenjoyed. \nO Anxiety: The child may become anxious and, \ntense, and feel panic. \nO Turmoil: The child may feel worried and \nirritable. The child may lash out in anger \nresulting from the distress he/she is feeling. \nO Regression: The child may revert to acting \nlike a baby. bedwetting, clinging and \ndemanding extra care. \nEFTA00006056\n\nVision \nJustice for all crime victims. \nMission Statement \nWith compassion and respect, we assist \nvictims of sexual assault, domestic violence, \nhomicide, and other violent crimes through \ncrisis response, advocacy, therapy, and \ncommunity awareness. \nFlorida Statute 960 Provides \nGuidelines For Fair lFeatment \n& Specific Rights For Victims \nIn The Criminal Justice System \nSome of these include the following: \nO Office of Attorney General Crime Victim \nCompensation, when applicable; \nO lb be informed, present, and heard, when \nrelevant at all crucial stages of criminal or \njuvenile proceedings, to the extent that right \ndoes not interfere with the Constitutional \nrights of the accused; \n0 lb be provided information concerning \nservices available including Victim \nCompensation, community treatment \npnagrams, crisis intervention services, \ncounseling and social services; \n0 lb a prompt and timely disposition of the case. \nto the extent that this right does not interfere \nwith the Constitutional rights of the accused; \n0- lb have your property returned to you as soon \nas possible after the investigation and/or \nprosecution is completed, unless there is a \ncompelling reason for its retention; \nO Have a Victim Advocate present during \ndepositions of the victim; \n0 Request, for specific crimes, an exemption \nprohibiting the disclosure of information to \nthe public which reveals your identification. \nPalm Beach County \nPublic Safety Department \nVictim Services Division \nwww.pbcgov.comipublicsafety/victimservices \n24/7 SEXUAL ASSAULT \nVIOLENT CRIME HELPLINE \nHELPLINE: (561) 833.7273 \nTOLL FREE: (866) 891.7273 \nMain Courthouse \n205 North Dixie Hwy., Suite 5.1100 \nWest Palm Beach, FL 33401 \n(561) 355-2418 option 3 \nTTY: (561) 233.2595 \nVictim Services SART Center \n4210 North Australian Ave. \nWest Palm Beach, FL 33407 \n(561) 625.2568 option 1 \nTTY: (561) 624.6520 \nNorth County Courthouse \n3188 PGA Blvd., Suite 1436 \nPalm Beach Gardens, FL 33410 \n(561) 355-2418 option 3 \nTTY: (561) 624.6643 \nSouth County Courthouse \n200 West Atlantic Ave., Suite 1E-301 \nDelray Beach. FL 33444 \n(561) 274.1500 \nTTY: (561) 274-1015 \nWest County-Glades Courthouse \n2976 State Road 15. 2nd Floor \nBelle Glade, FL 33430 \n(561) 996.4871 \nTTY: (561) 992-1113 \nServices are provided to all crime victims in Palm Beach \nCounty regardless of the victims' race, sex. color, religion. \nnational origin, disability, age, sexual orientation. marital \nstatus, or gender identity or expression. \nServices are funded through Palm Beach County Board of \nCounty Commissioners with grants from the Office of the \nAttorney General and Florida Council Against Sexual Violence. \nPalm Beach County \nBoard of County Commissioners \nN May 2015 \nlike Us on \nPISCVIcUrrtServices \nPalm Beach County \nPublic Safety Department \nVictim Services Division \nVictim Services \n& Certified \nRape Crisis Center \nServing Victims of Violent Crimes \nEFTA00006057\n\nSexual Assault \nDomestic Assault \nServices Provided \nProfessional butting and community \npresentations are also available. \nO. Information about Victims' rights \n4. 24-hour crisis response to hospitals, law \nenforcement agencies and crime scenes \n0 Sexual Assault Nurse Examiner (SANE) and a \nForensic Exam site ti The Butterfly House \n4 Sexual Assault Response Team (SART) \nto provide Victim-centered assistance \n-4 Criminal Justice advocacy and \ncourt accompaniment \n4 Assistance with filing State Crime \nVictim Compensation applications and \nRestraining Orders \nO Individual therapy and support groups \n0 Information and referral to community \nresources, including shelters and Legal Aid \nPalm Beach County provides equality of services and \ncare to everyone, regardless of people's age, disability. \ngender, gender identity, race, religion or belief or \nsexual orientation. \nSexual Assault is a violent crime including rape, \nincest, sexual harassment or any other sexual \ncontact without consent. \nPer Florida Statute 90.5035. a victim of sexual \nviolence who consults a sexual assault counselor at \na rape crisis center has the right to confidentiality of \ninformation shared with the counselor. \nNo one except the victim can compel the sexual \nassault counselor to reveal information about their \ncommunications. Only the victim can waive the \nprivilege, and this must be done in writing. \nIf rape victims are not sure whether to report to law \nenforcement, victim advocates will assist them \nthrough their decisionmaking process, respecting \nwhatever choices are made. \nCertified Rape Crisis Victim Advocates \nWill Provide: \n4 Crisis Intervention and Personal Advocacy \nAccompaniment during forensic rape exams at \nThe Butterfly House and other medical facilities \n0 Coordination of follow-up medical care, therapy \nand referrals \n4 Criminal Justice advocacy and court accompaniment \nStart by MS, \nBelieving \nStart by Believing: A Public \nAwareness Campaign to Change \nthe Way We Respond to Sexual \nViolence in Our Community... \none response at a time. \nYOUR REACTION MAKES THE DIFFERENCE. \nWhen someone tells you they've been raped. there's a \nsimple response. Start by Believing. \nDomestic Assault involves power and control \ntactics such as physical violence. emotional abuse, \nsexual violence, economic abuse, and isolation. \nVictim Advocates Will Provide: \nCrisis Intervention \n4 Safety Planning \n0 Assistance with filing Restraining Orders \n0 Safe-Shelter Referrals \n4 Personal and legal advocacy during \ncriminal justice proceedings \nHomicide and \nOther Violent Crimes \nHomicide and other violent crimes shatter the \nlives of injured victims and survivors causing \nsevere emotional trauma and grief. \nVictim Advocates Will Provide: \n4 Crisis Intervention and emotional support \nfor victims and surviving family members \n0 Assistance with filing crime victim \ncompensation for medical expenses. \nfuneral costs and loss of support \n4 Court Accompaniment \n4 Referrals for individual therapy, support \ngroups and community assistance \nEFTA00006058\n\nHelp is Available \nVictims of sexual crimes need \ncompassion, sensitivity and empathy. \nBeing the victim of a crime can be \noverwhelming. Your reactions are normal. \nLocal certified rape crisis centers have \nadvocates who are there to help all \nvictims, regardless of whether or not \nthey report to law enforcement. \nServices are free and confidential —\ncertified rape crisis centers are legally \nand ethically required to protect your \nconfidentiality, unless you allow, in \nwriting, the release of your information. \nAdvocates are available to: \n• Provide crisis intervention \n• Speak to you on the 24-hour hotline \n• Discuss your options \n• Navigate available resources \n• Go with you to appointments \n• Address safety concerns \n• Advocate on your behalf \n• Help you apply for victim compensation \nSexual Battery is a Crime! \nIn Florida, the legal term for rape or \nsexual assault is sexual battery (F.S. \n794.011). Sexual battery means oral, \nanal, or vaginal penetration by, or union \nwith, the sexual organ of another or the \nanal or vaginal penetration of another by \nany other object, committed without your \nconsent. \nConsent means Intelligent, knowing, \nand voluntary consent and does not \ninclude coerced submission. Failure to \noffer physical resistance to the \noffender does not imply consent. \nA person under 16 years of age \ncannot legally consent to sex. Also, a \nperson 24 years of age or older or a \nperson in a familial or custodial \nposition of authority cannot receive \nconsent from 16 and 17 year old \nminors. \nForensic Exam \nWhat is a forensic exam? \nThe forensic exam is a head-to-toe exam to collect \nevidence and check for injuries after a sexual crime. \nWhat are my rights with regard to the \nexam? \n• Stop the exam at any time \n• Have an advocate from a rape crisis center with \nyou \n• Be informed about the status of the kit during \nprocessing \nWhat evidence is collected? \nDuring the exam, the medical professional may collect \nblood, urine, saliva, pubic hair combings and/or nail \nsamples. They may also collect items of your clothing. \nThey will ask you questions about the crime and your \nmedical history in order to help them collect evidence. \nWhat happens to the evidence? \nIf you make a report to law enforcement, your kit will \nbe sent to the regional or statewide lab within 30 \ndays for testing. The lab is required to process the kit \nwithin 120 days. \nIf you don't report the crime to law enforcement at \nthe time you obtain the exam, your kit will be stored \nanonymously. Your kit may be stored for only a \nlimited time, depending on your community's storage \nspace. The local rape crisis center can advise you \nabout the storage timelines in your community. \nEFTA00006059\n\nYou have the right to: \n• Obtain a forensic exam whether or not you report \nto law enforcement \n• Have an advocate at the forensic exam with you \n• Have the forensic exam sent for testing within 30 \ndays, if reported to law enforcement \n• Review the law enforcement report prior to final \nsubmission \n• Be informed, present, and be heard at all crucial \nstages of the criminal or juvenile proceeding \n• Have an advocate with you during a discovery \ndeposition \n• Have identifying information about the criminal \ninvestigation kept confidential \n• Have the offender, if charged, tested for HIV and \nhepatitis \n• Attend sentencing or disposition of the offender \n• Notification of judicial proceedings and scheduling \nchanges \n• Notification about the release of incarcerated \noffender \n• Request restitution \n• Give a victim impact statement \n• Not be subjected to a polygraph \n• Take up to 3 days of leave from work (with eligible \nemployer) \n• Apply for an injunction if you fear for your safety or \noffender is nearing release \nVictim Compensation \nYou may be eligible for \nfinancial assistance for: \n• Medical Care \n• Lost Income \n• Mental health services \n• Relocation \n• Other expenses related to injuries as a result \nof the crime \nContact your local certified rape \ncrisis center for more information. \nThis project was supported by Grant \nNo. 2015-WL-AX-0037 awarded by \nthe Office on Violence Against Women, \nU.S. Department of Justice. The \nopinions, findings, conclusions, and \nrecommendations expressed in this \npublication are those of the author(s) \nand do not necessarily reflect the views \nof the Department of Justice, Office on \nViolence Against Women. \nResources \nFlorida Council Against Sexual Violence \n1-888.956-7273 \nwww.fcasv.org \nVictim Compensation \n1-800-226-6667 \nwww.myfloridalegal.com \nFlorida Department of Law Enforcement \nSexual Offender/ Predator Unit \n1-888-357-7332; 1-850.410.8572 \nFor TTY Accessibility: 1-877-414-7234 \nE-mail: sexpred@fdle.state.fl.us \nFlorida Department of Corrections \nVictim Information and Notification Everyday \n(VINE) \n1-877-VINE-4-FL \nwww.dc.state.fLus/othivictasst/index.html \nFlorida Abuse Hotline \n1-800-962-2873 \nLocal Rape Crisis Center \nPalm Beach County Victim Services \n& Certified Rape Crisis Center \nVictim Services SART Center \n4210 North Australian Avenue \nWest Palm Beach, FL 33407 \nOffice: 561-625-2568 \nHelpline: 866-891-RAPE (7273) \nwww.pbcgov.com/publicsafety/ \nvictimservices \nAWN 2ol . 40:0 \nEFTA00006060\n\nCenter for Trauma Counseling \nWhere Your Emotional Healing Can Begin \nA non-profit Community Counseling Center \nServing Palm Beach County and beyond \nIndividual, Couples, Family, & Group Therapy \nServices for Children (3 y/o) to Adults (99 +) \nWe offer affordable counseling services to those that are insured and not insured. \nInsurance accepted: Cigna, Humana Commercial, Magellan, Beacon (Humana Medicaid, \nCoventry) \nSliding Scale: Reduced fees based on income for those who qualify \nLanguages Spoken: English, Spanish, and Farsi \nEvidence Based Models: Play/Sand Tray therapy, EMDR, Trauma Focused Cognitive Behavioral \nTherapy \nHours: Monday-Friday, Saturdays and evening appointments available \nReferral Process: Call 561-444-3914 (Office) email: info@palmbeachmentalhealth.org \nCenter for Trauma Counseling, Inc. \n6801 Lake Worth Road, Suite 307 \nGreenacres, FL 33467 \nOffice: 561-444-3914 \nwww.parrnbeachmentalhealth.org \nEFTA00006061\n\nOffice of the Attorney General \nThe Capitol. PL-01 • Tallahassee, FL 3230-1050 . Office: (800)2264687 Fax: (853) 414.6191 \nBill Status Inform:tier for Providers 050) 414-3331 • TDD users may call through Florida Relay Service at 1.803.9558771 \n'Nebsite: myfloridalegalcom • Email address: vointake@myfloridalegal.com \nBUREAU OF VICTIM COMPENSATION CLAIM FORM \nInstructions \nPlease read the Eligibility Requirements to see if you qualify for this program. Fill out this form completely (please print). attach all required \ndocumentation. and submit to the above address. I' you move or change your address. you are required to notify this office. \nCHECK THE TYPE Of VICTIM COMPENSATION BENEFITS YOU ARE REQUESTING: \nFl DISABILITY - compensation for the victim who suffered a Donnell cisatilty. \nI—I (Attach documentasn as cktined in Section 3.) \nEg\nWAGE LOSS - compensation fa the victm who lost wages due to crime related \nph \ninjuries (Math documentation as outlined in Section 3.) \nSS OF SUPPORT - compensation for the dependent(s) of a deceased victim \nwho was employed at the time of the crime. (Attach Cournentaticn as alined \nin Section 4.) \nEXPENSES • payment cc retnticrsenent on oehSt of the victim for cnme-retaed \nfuneral/burial, medical/dente treatment and mental health cornseing expenses: \nas well as aesoiptions, eyeglasses, dentures, ons prosthetic &Ake lost \ndamaged, or required because of \ncone. \n(Attach termed bels and receip \ntreatment/funeral \nO \nFUNERAL/BURIAL \nEDICALMENTAL \nNTAL HEALTWGRIEF \nTREATMENT \nCOUNSELING \nin EMERGENCY ASSISTANCE - relmtursement fu dixturnented wage bee and \nout-of-packet a/pauses related b da Came. (Attach receipts.) \nCHECK ALL OTHER TYPES OF 8 ENEFFS YOU ARE REOUESTNG: (Separate claim numbes we be assigned.) \nIn PROPERTY LOSS for an Wuh over the age of 60 or enabled adult ,attach \nproof \ndisabity pre( to the dab) of nine from a physician a the Social Security \nAdministraton) who suflered the loss of tamable serSOna: property, as the restlt \nof a criminal or delinquent act. Math a receipt of written estinate train a vendor \nor merchant identifying lie comparable replacement value. Compensabie items \nmist be identified by the law enforcement report \nIn SEXUAL BATTERY RELOCATION ASSISTANCE - for the vctm of sexual \nCelery seeking assstance b relocate due to reasonable fear A certified rape \ncrisis center certificatior form must be received with Ine appintion. \nSection 1. Victim and Applicant Information \nVICTIM'S NAME \n(lar. Net mcldle) \nSOCIAL \nSECURITY NO. \nADORE \nTELEPHONE \nNUMBER \nALTERNATE\nPHONE NUMBER \nTITS INFORMATION IS COLLECTED FOR FEDERAL REPORTING PURPOSES AND IS OPTIONAL. \nRAMETHINICEY CIMAERICAN 'MAW EIASLAN BLACIVATRICAN rl \nHISPANIC cr \nI--IkLASKA NATIVE \nI—I AMERICAN \nL.—I LATINC \n(- 1 DOMESTIC VIOLENCE RELOCATION ASSISTANCE - be the victim of \ndonestc violence seeking assistance to relocate to a sate environment. A \ncerifieo domesic violence certif talon form and applcaton nust be receved \nwith 33 days horn the date of crime. \nri \nHUMAN TRAFFICKING RELOCATION ASSISTANCE - for the vctiir of sexual \ntraffickng with an urgent need to relocate. A rape orals or domestic ‘iolence \ncerter cerbicaton fern and applicator] must be received within 45 days of the \nlast identifiable threat. \nCCCUPATICe gala wv-ety.r.va,A-\nO NATIVE HAWAIIAN or OTTER PACIFIC ISLANDER K \nOTHER RACE \nO eiLLTIRE RACES \nWHITE NONLKINOCAUCASIAN \nGENDER: ti \n!it \nThe applicant temp on peep* of a 'kern is required to provide clamant information below. When requestng compensation cn behalf of an incompetent adult victim prcol \nof legal guardianship must be attached, and the applicant's signature an tie dairr form must oe witnessed by a Notary Public. \nIS THE VICTIM icheo ore) \nDECEASED O INJURED MINOR \nK \nAl" INJ WITNESS" O INCOMPETENT \nNOT \nURED \nAPPLICANT NNE \nBed. first middle) \nDATE OF \nBIRTH \n/ \n/ \nSOCIAL \n' E-MAIL \nSECURITY NO. \nI ADDRESS \nWOULD YOU UKE ALL CORRESPONDENCE \nSENT BY EMAIL? \nYES \nNO \nADDRESS \nCITY \nSTATE \nZIP \nCODE \nTEL EPHosE / \nTAMER \nk \nALTERNATE \ni\nPHONE NUMSER k \nRELATIONSHIP \nTO vICTIM \nOCCUPATION \nNATIONAL ORIGIN \nlikS P1 \nWAS VICTIM DISABLED \nBEFORE THE CRIME OCCURRED? \nD YES \nEIVC lee Vt15) \nThe Mee of the Attorney General. Bureau of Victim Compensation is an equal opportunity provider and empasyer. \nPage 1 of it \nEFTA00006062\n\nSection 2. Referral Source Information \nIndividuals who assisted with or filled out any sections of this application are required to provide referral information below. By signing this applicatior, the victim/applicant \naffirms that all information provided is true and correct, and thus. al sections should be reviewed before the application is signed. (Treatment providers can request \ntraining on the Victim Compensation Program. which is recommended prior to becoming a referral source.) \nMME OF PERSON ASSISTING WITH APPLICATION \nI EMAIL \npast first mimic) \nADDRESS \nhAME OF AGENCY/ORGANIZATION \nAGENCY ORGANZATIONS ADDRESS \n(address. city, state, zip code) \nSection 3. Disability or Lost Wages Information \nMen westing ceneersatcrfor bst %vars.tech a copy ofyour ray stub or conics staterrynt atiich 'decrees you eTploinert stale WO wages ate tee d the CAM V)0ll ae Semple* \nor voider a trtiyrnenter, attach a spay of yet blest barna tax ream aril apckabe MS schedule tarns. If mot than 5 work days were meted as a rasa d the crime Malta &dors bear \nwtich erased you kr tag abseret When leclAstril dsatilY COMPenSaf011, alath a dactyls letter neon speaks each cite related penmen( cisabity rang exoreIng bleanest:an lAeckal \nAssoParn Gtitlekes ar Sktifia Imparrre7t Patric Gudekes. and favrad &oat SepolykInwasaatcr award leders \nELEPHQNE\nNUMBER\nSUPERVISOR'S WE \nliAl.E OF COMPANY/BUSINESS \nle we ban ere In ernotiyar,pkeie mach looms 'heel \nCONPAINY ADDRESS \nIaddress. city state, zip code) \nIS WAGE LOSS COVERED BY INSURANCE? \nLI YES \nIS WAGE LOSS COVERED BY WORKER'S COMPENSATION? I-1"° \nYES \nTELENCINIE\nWEER \n)\nNIJ \nIS VICTIM DISABLED AS A RESULT OF THE CRIME? \nn \nYES \nI I NO \nn NO \nSection 4. Loss of Support Information or Grief Counseling Information \n'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 attach a copy of the deceased victim's \n3t•eSI income tar rein and individual earnings statement reemploynont assistance benefit statement. tour rimer for support. birth mrtficate which idenbfies dependent \nviationship, marriage cerhficato, or legal documentation proving principal suapidt. \nDEPENDANTAUNCR CLAINAN- NAME(S) \nDATE OF BIRTH \nRELATIONSHIP TO MTN \nSection 5. Insurance Information \nClements who are determined eligible for the Vctim Compensation and Prcoerty Loss Program may be 'mem( Iran the irsurance deductble or co-payment provisions Of \ntheir insurance policyQes). \nIS INSURA.NCE OR MEDCAJD AVAILABLE TO ASSIST WITH THESE EXPENSES? \nO YES \nNO \nMEDICAID NUMBER \nyes, prende be foaming ix d inwrance paces. including lAerliceid Medicare. Flo hanoonnoq. ailomobit, or moice medal &tad as related insdarce Expknabcn Of Senses statardends). \ni COMPANY NAME \nAV-C (AM ilVt WAWA \nNUMBE \n0 - 40 \n- 115 - 258- 5 \nADDRESS \nCITY \nZIP \nCODE \n2. COMPANY NAME \nPOLICY NUMBER \nTELEPHONE/\nNUMBER \nADDRESS \nCITY \nSTATE \nZr \nCODE \nI TELEPHRONE/ \nSection 6. Other Compensation, Settlement, and Attorney Information \nYou must notify this off ce if ye/ have race yea or f yrn antapate receiving compensation or any benefits from any tithe source as a result of this inadent. You must also \nnotify this office if you have or are laming to hire an attorney to represert you as a result of the incident \nSTATE THE SOURCE AND \nDATE RECEIVED (IFAPFUCAN1) \n0 I ‘S-I t 41 \nI ARE YOU REPRESEN-ED_ / \nI \nBY LEGAL COUNSEL? L'\nS 0 NO \nATTORNEY'S NAME \nI \nADDRESS \nEMAIL \nADDRESS \nI TELEPHONE \nNUMBER \nCITY \nSTATE \nZIP \nCODE \n\\\nBY; 100 tits) \nThe Office of the Attorney General, Bureau of Victim Compensation is an equal oeportoney provider and employe, \nPogo 2 of 4 \nEFTA00006063\n\nSection 7. Crime Information \nThis section must be completed and proof of Crime (such as a law enforcement report a charging affidavit) must be attached. Failure to submit proof of crime wit result in \nyour application not being processed or your claim being denied. \nNAME OF LAW \nDATE OF \nCRIME \nI DATE REPORTED TO LAW \nENFORCEMENT AGENCY \nENFORCEMENT AGENCY \nWAS THE CRP& \nj\n \nREPORTED TO LAW ENFORCEMENT WITHIN 72 HOURS? \nYES \nONO \nIf no. please explain. (II no. failure to provide an acceptable explanation in this section will result in a denial of beneib.) \nIS THE APPLICATION AND LAW ENFORCEMENT REPORT BEING SUBMITTED WITHIN ONE YEAR FROM THE DATE OF CRIME? K YES 13 NO \nIf no, please explain. (Please be advised that most benefits apply to treatment losses suffered within one year from the date of crane. with sane exceptions for minor wan \nII no. Mime to Monde an %Made explanation in this seams MI result n a denial of bonen.) \nTYPE OF CRIME AS SPECIFIED \nON THE LAW ENFORCEMENT REPORT \nNAME OF LAW \nENFORCEMENT OFFICER \nNME OF ASSISTANT STATE ATTORNEY \nHANDLING THE CASE Of applicatle) \nLAW ENFORCEMENT \nREPORT NUMBER \nSection 8. Eligibility Requirements \nNAME OF OFFENDER \nNlmoitin) \nSTATE ATTORNEY! \nCLEW OF COURT CASE NUMBER (if appicable) \nAdditional qualification criteria. deadlines, and exceptions not listed may apply. \nVictim Compensation (VC): The victim must cooperate fuly with law enforcement officials, State Attorneys Office, and the Attorney General's Office. The clime \nmust be reported to law enforcement within 72 hours, unless there is good cause for delayed reporting. The claim must be filed Within one year after the date \nof the crime or within two years when there is good reason for not fling within one year. Exceptions for filing time requirements apply to victims who are minors. \nThe victim must not have engaged in an unlawful activity or contributed to the situation that brought about his or her own injury or death. The victim must have \nsuffered a physical, psychiatric, psychological injury, or death as a result of the crime. \nProperty Loss (PL): The victim must have suffered a substantial diminution in their quality of life from the loss of tangible personal property as the result of a \ncriminal or delinquent act. Property loss reimbursement is available up to $500 on any one claim and a lifetime maximum of $1,000 on all claims. \nDomestic Violence Relocation Assistance (DV): The victim must need immediate assistance to escape a domestic violence environment. The application must \nbe filed within 30 days after the domestic violence crime. Certification by a certified domestic violence center in the State of Florida is required. The victim must \nsubmit estimates, invoices, or receipts for interim lodging, housing, utility deposits, new cellular phone service, transportation, moving company expenses, or \nemergency food or clothing. \nRelocation for Victims of Sexual Battery (RS): The victim must need to relocate due to a reasonable fear for his or her safety. Certification by a certified rape \ncrisis center in the State of Florida is required. The victim must submit estimates, invoices, or receipts for interim lodging, housing, utility deposits, new cellular \nphone service. transportation, moving company expenses, or emergency food or clothing. \nHuman Trafficking Relocation Assistance (HT): The victim must have an urgent need to escape from an unsafe environment directly related to a sexual human \ntrafficking offense. Application must be received within 45 days of the last identifiable threat by a human trafficking offender. The identifiable threat must have \nbeen communicated with the proper authorities. Certification from a certified rape crisis or domestic violence center in the State of Florida is required. The victim \nmust submit estimates, invoices or receipts from interim lodging, housing, utility deposits, new cellular phone service, transportation, moving company expenses, \nor emergency food or clothing. \nCriminal History Record Check: In order for compensation to be considered, the victim or applicant must not have been confined or in custody in a county \na municipal facility; a state or federal correctional facility; or a juvenile detention commitment. Or assessment facility; adjudicated as a habitual felony offender. \nhabitual violent offender, or violent career criminal; or adjudicated of a forcible felony offense. \nNotice of Payment Limitations: The Bureau of Victim Compensation may provide financial assistance for eligible persons, but only after all other sources of \n. payment have been exhausted. Payments accepted by in-state providers on behalf of victims are considered payment-in-full per Florida Statute. Total victim \ncompensation benefits cannot exceed the maximum award amount determined by the current benefit payment schedule. Limits below the maximum may ipty to \nspecific benefits, which may be reduced without prior notice to the award recipient based on the availability of funding. \nAcceptable Proof of Crime: The Bureau of Victim Compensation does not make an independent judgment on whether a compensable crime occurred, but \ninstead relies on proof of crime from the proper authorities. Failure to provide acceptable documentation proving that a compensable crime occurred shall result \nin your application not being processed or your claim being denied. Acceptable documentation includes: a law enforcement report or charging affidavit from \na child protection team, law enforcement agency, state or prosecuting attorney. or the Department of Children and Families that affirms a compensable crime \noccurred; an indictment by a grand jury; an indictment by a prosecutor from a court of competent jurisdiction; a report from the United States Federal Bureau of \nInvestigation; or a Florida Department of Law Enforcement cybercrime investigator certification of a crime for purposes of Section 960.197, F.S. \nComplete Application Package: It is your responsibility to provide a complete application package which includes acceptable documentation proving that a \ncome occurred. If the department receives a report which is insufficient for proving that a compensable crime occurred, the application will be assigned a claim \nnumber and denied. Claim numbers assigned are not indicative of eligibility or denial. For assistance with collecting acceptable documentation. please contact \nyour local law enforcement agency, the agency where the crime was reported, the referral source, or your local State Attomey's Office. \nBVC 100 (7/15) \nThe Office of the Attorney General, Bureau of Victim Compensation is an equal opportunity provider and employer. \nPage 3 of 4 \nEFTA00006064\n\nPLEASE READ CAREFULLY AND SIGN THE FOLLOWING CERTIFICATIONS \nSection 9. \nCONFIDENTIALITY: If you are Ire victim of a sexual battery. aggravated chid abuse. aggravated stalking, harassment, aggravated battery, or domestic \nviolence. you have the rignt to have information about your home address and telephore number, employment address and telephone number, and your \npersonal assets, kept confidential for a period of five years. If you are the victim of any of these crimes, please mark one of the following statements. Your \nresponse will not affe the processing of your claim. \nI want the information to be confidential \nO \nI do NOT want the information to be confidential \nSERIOUS FINANCIAL HARDSHIP: I certify that I have a senous financial hardship because of crime-related expenses that cannot be paid by any other \nsource. \nPROPERTY LOSS CERTIFICATION: I eerily that the property in question belonged to the victim: that this loss adversely affects the victim's quality of life: \nthat there is no other source of reimbursement for this loss; and that replacement of the prope-ty would cause the claimant a serious financial hardship. \nRELEASE OF INFORMATION: I give permission to any hospital, doctor. dentist, mental health counselor, or other treatment provider, bankng triStrtution, \nsocial service agency, law enforcement agency. corrections agency, state attorney's office, inssance carrier, attorney or employer to give out information that \nis requested concerning any treatment rendered, employment Insurance thrd-party payer, or law enforcement nvestigative information to the Department \nof Legal Affairs for use in processing my dom. I give permission lo the Department to release information about the status of my claim to any treatment \nprovider, law enforcement agency. or state attorney's office. \nSOCIAL SECURITY NUMBER DISCLOSURE: The Bureau cf Victim Compensation collects and uses Social Security numbers for the purpose of performing \nmperatve duties and responsiNifieswtoch may include the forowing: searching criminal history records. identity management. biting and payments, benefit \nprocessing. and reporting to authorized state and federal government agencies. Failure to provide this optimal information may delay lhe processing of your \napplication or benefits. Federal and State laws fracture the Bureau to protect Social Security numbers from disclosure to ulauthoized parties. Absent a waiver \nfrom you or your legal representative Social Security numbers will be redacted. unless the agency receives a court order to turn over a ron redacted file. \nREPAYMENT REQUIREMENT: I understand that payment by the victim compensation program is a payment of last resort and that I must repay the Crimes \nCompensation Trust Fund if I receive a victim compensation award and also receive payment from another source as a result of the same crrninal incident \nOtter 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. \nI further understard that I must repay any emergency award from the Cnmes Compensation Trust Fund, If my claim is determined ineligible. I also understand \nthat if my eligibility is withdrawn, I must repay any amount received from the Crimes Compensation Trust Fund. \nAPPLICANT: Applcant signature is required if Mine as the parent. legal guardian. a individual authorized to administer a vctirts estate. \nPnnted Name: \nSignature: \nDate.\nUnder Penalty of Perjury or fraud, the information I have provided is true and correct to the best o' my knowledge. \nNOTARIZATION REQUIREMENT: Persons submitting an application on behalf of an incompetent adult must sibmit prin.,' or legal guarcianship \nand have their signalize mtnessed by a Notary Public. \nSworn to and subscribed oefore nit this \nday of \n. 20 \nPersonalty known to me. \nIdentification produced. \nVotary Pottle Signature: \nStamp/Seal: \nBVC 10i (-7/15) \nThe Office or the Attorney General, Bureau of Victim Compensation is en equal opportunity provider rid employer \nPage 4 of 4 \nEFTA00006065\n\n--- Page Break ---\n\nVision \nJustice for all crime victims. \nMission Statement \nWith compassion and respect, \nwe assist victims of sexual \nevil- et, domestic violence, \nhomicide, and other violent \ncrimes through crisis response, \nadvocacy, therapy, and \ncommunity awareness. \nPalm Beach County \nVictim Services \nis a Certified Rape Crisis Center \nthat provides therapy services to \nall crime victims in Palm Beach \nCounty regardless of the victims' \nrace, sex, color, religion, national \norigin, disability, sexual \norientation, marital status, \nfamilial status or gender identity \nor expression. \nStart by Believing: \nStart by \nr \nA Public Awareness \nBelieving \nCampaign to \nChange the Way \nWe Respond to Sexual Violence in Our \nCommunity... one response at a time. \nYOUR REACTION \nMAKES THE DIFFERENCE. \nWhen someone tells you they've \nbeen raped. there's a simple response. \nStart by Believing. \nkilo. \nit . tr.; \ncounty \nSafety .Department \njiiiedin Services Division\nwwwpbcgov.com/publitsafety/victimSeeVicett \n24/7 SEXUAL ASSAULT \nVIOLENT CRIME HELPLINE \nHELPLINE: (561 -8$3`7273 \nTOLL FREE: (866) 891.7273 \n1:.N \nEoi rehouse \n-'205 45itil Utile Hwy , Suite 5.1109 \nWest Palm Beach. FL 33401 \n(561) 355-2418 option 3 \nTTY: (561) 233-2595 \nVictim Services SART Center \n42113 North Australian Ave. \nVilest Palm Beach. FL 33407 \n(561)625.2568 option 1 \n• \nTIT (561) 6244520 \nNoith County Courthouse \n3188 PGA Blvd.. Suite 1436 \nPalm Beach Gardens, FL 33410: \n(561) 355-2418 option 3 \n' \n(561) 624.6643 \nSouth County Courthouse \n200. West lykraje Ave., Suitt E-301 \nDenyW4aeh. \n(50) 274:1500 \nITV: (561) 274-1015 \nes" \nWest County-Glades Courthouse \n2976 $tate n&d 15. 2nd Floor \nBelle Glade, FL 33430 \n(561) 996-4871 \nITV; (561)992-1113.._ -.-\n--Like Us on \nprzvictimsgrytces \nSart-gifts are funded through Palm Beachtounty Board of \nCounty Cornthissioners with grants fronithe OKI& of the - \nAttorpeyGeneral and Honda Council Against Sexual Violence;;.,-. \n-0, \nPalm tescItCounly \nN\nPalm Beach \nti \n• '. \n'Public Saki< Denali Intent \niclim Sci viucs Di% is io \nSewing Victims of Violent Crimes \n1 \nEFTA00006055\n\nHave You Been \n,. \nA Victim Of A Crime? \nDo' Thu Experience \nAny Of The Following? \n* Inability to fall orstay asleep? \n* Feeling anxious or depressed? \n* Having outbursts of anger? \n* Inability to concentrate? \n* reeling emotionally numb? \n* Loss of interest in the things you used to enjoy? \n* Painful memories of the traumatic event? \n* Bad dreams about the traumatic event? \n* flashbacks or a sense of reliving the events? \n* Racing thoughts? \n* Physiological stress response to reminders of the \nevent? (pounding heart, rapid breathing, nausea, \nmuscle tension, sweating) \nPalm Beach County provides equality of services and \ncare to everyone, regardless of people's age, disability. \ngender. gender identity, race, religion or belief or \nsexual orientation. \nFree services include individual therapy \nfor children and adults and adult-support \ngroups. \nIf you are a crime victim or have been \na victim of crime in the past and are \nconsidering therapy, we welcome your coll. \nTherapists are available for appointments \nMonday through Friday, excluding legal \nholidays. \nTherapists Will Help You: \nO Identify trauma reactions \nO Explore the impact that trauma has on your daily life \nO Reduce the intensity of negative emotional \nresponses and symptoms \nO Learn about common trauma reactions and \nphases in healing \nO Feel hopeful and positive regarding the future \nO Develop coping mechanisms to utilize when \nthinking or talking about the crime \nO Experience a reduction of trauma symptoms \nO Return to work or school \nO Explore the impact on current and future \nrelationships \nerapy For \nChildren & Teenagers \nO Assessment and treatment for child victims \nof crime\nO Therapeutic interventions that teach \nchild safety \n• \n.0 Play Therapy \n.0 Assistance for parents during this \ndifficult time \nSigns Of lPauma In Children \nO Sadness: The child may feel despondent or \nhopeless The child may cry easily or withdraw/ \nisolate from others. \nO Loss of interest in activities: The child may \ncomplain of feeling "bored" or reject offers to \nparticipate in activities they have previously \nenjoyed. \nO Anxiety: The child may become anxious and, \ntense, and feel panic. \nO Turmoil: The child may feel worried and \nirritable. The child may lash out in anger \nresulting from the distress he/she is feeling. \nO Regression: The child may revert to acting \nlike a baby. bedwetting, clinging and \ndemanding extra care. \nEFTA00006056\n\nVision \nJustice for all crime victims. \nMission Statement \nWith compassion and respect, we assist \nvictims of sexual assault, domestic violence, \nhomicide, and other violent crimes through \ncrisis response, advocacy, therapy, and \ncommunity awareness. \nFlorida Statute 960 Provides \nGuidelines For Fair lFeatment \n& Specific Rights For Victims \nIn The Criminal Justice System \nSome of these include the following: \nO Office of Attorney General Crime Victim \nCompensation, when applicable; \nO lb be informed, present, and heard, when \nrelevant at all crucial stages of criminal or \njuvenile proceedings, to the extent that right \ndoes not interfere with the Constitutional \nrights of the accused; \n0 lb be provided information concerning \nservices available including Victim \nCompensation, community treatment \npnagrams, crisis intervention services, \ncounseling and social services; \n0 lb a prompt and timely disposition of the case. \nto the extent that this right does not interfere \nwith the Constitutional rights of the accused; \n0- lb have your property returned to you as soon \nas possible after the investigation and/or \nprosecution is completed, unless there is a \ncompelling reason for its retention; \nO Have a Victim Advocate present during \ndepositions of the victim; \n0 Request, for specific crimes, an exemption \nprohibiting the disclosure of information to \nthe public which reveals your identification. \nPalm Beach County \nPublic Safety Department \nVictim Services Division \nwww.pbcgov.comipublicsafety/victimservices \n24/7 SEXUAL ASSAULT \nVIOLENT CRIME HELPLINE \nHELPLINE: (561) 833.7273 \nTOLL FREE: (866) 891.7273 \nMain Courthouse \n205 North Dixie Hwy., Suite 5.1100 \nWest Palm Beach, FL 33401 \n(561) 355-2418 option 3 \nTTY: (561) 233.2595 \nVictim Services SART Center \n4210 North Australian Ave. \nWest Palm Beach, FL 33407 \n(561) 625.2568 option 1 \nTTY: (561) 624.6520 \nNorth County Courthouse \n3188 PGA Blvd., Suite 1436 \nPalm Beach Gardens, FL 33410 \n(561) 355-2418 option 3 \nTTY: (561) 624.6643 \nSouth County Courthouse \n200 West Atlantic Ave., Suite 1E-301 \nDelray Beach. FL 33444 \n(561) 274.1500 \nTTY: (561) 274-1015 \nWest County-Glades Courthouse \n2976 State Road 15. 2nd Floor \nBelle Glade, FL 33430 \n(561) 996.4871 \nTTY: (561) 992-1113 \nServices are provided to all crime victims in Palm Beach \nCounty regardless of the victims' race, sex. color, religion. \nnational origin, disability, age, sexual orientation. marital \nstatus, or gender identity or expression. \nServices are funded through Palm Beach County Board of \nCounty Commissioners with grants from the Office of the \nAttorney General and Florida Council Against Sexual Violence. \nPalm Beach County \nBoard of County Commissioners \nN May 2015 \nlike Us on \nPISCVIcUrrtServices \nPalm Beach County \nPublic Safety Department \nVictim Services Division \nVictim Services \n& Certified \nRape Crisis Center \nServing Victims of Violent Crimes \nEFTA00006057\n\nSexual Assault \nDomestic Assault \nServices Provided \nProfessional butting and community \npresentations are also available. \nO. Information about Victims' rights \n4. 24-hour crisis response to hospitals, law \nenforcement agencies and crime scenes \n0 Sexual Assault Nurse Examiner (SANE) and a \nForensic Exam site ti The Butterfly House \n4 Sexual Assault Response Team (SART) \nto provide Victim-centered assistance \n-4 Criminal Justice advocacy and \ncourt accompaniment \n4 Assistance with filing State Crime \nVictim Compensation applications and \nRestraining Orders \nO Individual therapy and support groups \n0 Information and referral to community \nresources, including shelters and Legal Aid \nPalm Beach County provides equality of services and \ncare to everyone, regardless of people's age, disability. \ngender, gender identity, race, religion or belief or \nsexual orientation. \nSexual Assault is a violent crime including rape, \nincest, sexual harassment or any other sexual \ncontact without consent. \nPer Florida Statute 90.5035. a victim of sexual \nviolence who consults a sexual assault counselor at \na rape crisis center has the right to confidentiality of \ninformation shared with the counselor. \nNo one except the victim can compel the sexual \nassault counselor to reveal information about their \ncommunications. Only the victim can waive the \nprivilege, and this must be done in writing. \nIf rape victims are not sure whether to report to law \nenforcement, victim advocates will assist them \nthrough their decisionmaking process, respecting \nwhatever choices are made. \nCertified Rape Crisis Victim Advocates \nWill Provide: \n4 Crisis Intervention and Personal Advocacy \nAccompaniment during forensic rape exams at \nThe Butterfly House and other medical facilities \n0 Coordination of follow-up medical care, therapy \nand referrals \n4 Criminal Justice advocacy and court accompaniment \nStart by MS, \nBelieving \nStart by Believing: A Public \nAwareness Campaign to Change \nthe Way We Respond to Sexual \nViolence in Our Community... \none response at a time. \nYOUR REACTION MAKES THE DIFFERENCE. \nWhen someone tells you they've been raped. there's a \nsimple response. Start by Believing. \nDomestic Assault involves power and control \ntactics such as physical violence. emotional abuse, \nsexual violence, economic abuse, and isolation. \nVictim Advocates Will Provide: \nCrisis Intervention \n4 Safety Planning \n0 Assistance with filing Restraining Orders \n0 Safe-Shelter Referrals \n4 Personal and legal advocacy during \ncriminal justice proceedings \nHomicide and \nOther Violent Crimes \nHomicide and other violent crimes shatter the \nlives of injured victims and survivors causing \nsevere emotional trauma and grief. \nVictim Advocates Will Provide: \n4 Crisis Intervention and emotional support \nfor victims and surviving family members \n0 Assistance with filing crime victim \ncompensation for medical expenses. \nfuneral costs and loss of support \n4 Court Accompaniment \n4 Referrals for individual therapy, support \ngroups and community assistance \nEFTA00006058\n\nHelp is Available \nVictims of sexual crimes need \ncompassion, sensitivity and empathy. \nBeing the victim of a crime can be \noverwhelming. Your reactions are normal. \nLocal certified rape crisis centers have \nadvocates who are there to help all \nvictims, regardless of whether or not \nthey report to law enforcement. \nServices are free and confidential —\ncertified rape crisis centers are legally \nand ethically required to protect your \nconfidentiality, unless you allow, in \nwriting, the release of your information. \nAdvocates are available to: \n• Provide crisis intervention \n• Speak to you on the 24-hour hotline \n• Discuss your options \n• Navigate available resources \n• Go with you to appointments \n• Address safety concerns \n• Advocate on your behalf \n• Help you apply for victim compensation \nSexual Battery is a Crime! \nIn Florida, the legal term for rape or \nsexual assault is sexual battery (F.S. \n794.011). Sexual battery means oral, \nanal, or vaginal penetration by, or union \nwith, the sexual organ of another or the \nanal or vaginal penetration of another by \nany other object, committed without your \nconsent. \nConsent means Intelligent, knowing, \nand voluntary consent and does not \ninclude coerced submission. Failure to \noffer physical resistance to the \noffender does not imply consent. \nA person under 16 years of age \ncannot legally consent to sex. Also, a \nperson 24 years of age or older or a \nperson in a familial or custodial \nposition of authority cannot receive \nconsent from 16 and 17 year old \nminors. \nForensic Exam \nWhat is a forensic exam? \nThe forensic exam is a head-to-toe exam to collect \nevidence and check for injuries after a sexual crime. \nWhat are my rights with regard to the \nexam? \n• Stop the exam at any time \n• Have an advocate from a rape crisis center with \nyou \n• Be informed about the status of the kit during \nprocessing \nWhat evidence is collected? \nDuring the exam, the medical professional may collect \nblood, urine, saliva, pubic hair combings and/or nail \nsamples. They may also collect items of your clothing. \nThey will ask you questions about the crime and your \nmedical history in order to help them collect evidence. \nWhat happens to the evidence? \nIf you make a report to law enforcement, your kit will \nbe sent to the regional or statewide lab within 30 \ndays for testing. The lab is required to process the kit \nwithin 120 days. \nIf you don't report the crime to law enforcement at \nthe time you obtain the exam, your kit will be stored \nanonymously. Your kit may be stored for only a \nlimited time, depending on your community's storage \nspace. The local rape crisis center can advise you \nabout the storage timelines in your community. \nEFTA00006059\n\nYou have the right to: \n• Obtain a forensic exam whether or not you report \nto law enforcement \n• Have an advocate at the forensic exam with you \n• Have the forensic exam sent for testing within 30 \ndays, if reported to law enforcement \n• Review the law enforcement report prior to final \nsubmission \n• Be informed, present, and be heard at all crucial \nstages of the criminal or juvenile proceeding \n• Have an advocate with you during a discovery \ndeposition \n• Have identifying information about the criminal \ninvestigation kept confidential \n• Have the offender, if charged, tested for HIV and \nhepatitis \n• Attend sentencing or disposition of the offender \n• Notification of judicial proceedings and scheduling \nchanges \n• Notification about the release of incarcerated \noffender \n• Request restitution \n• Give a victim impact statement \n• Not be subjected to a polygraph \n• Take up to 3 days of leave from work (with eligible \nemployer) \n• Apply for an injunction if you fear for your safety or \noffender is nearing release \nVictim Compensation \nYou may be eligible for \nfinancial assistance for: \n• Medical Care \n• Lost Income \n• Mental health services \n• Relocation \n• Other expenses related to injuries as a result \nof the crime \nContact your local certified rape \ncrisis center for more information. \nThis project was supported by Grant \nNo. 2015-WL-AX-0037 awarded by \nthe Office on Violence Against Women, \nU.S. Department of Justice. The \nopinions, findings, conclusions, and \nrecommendations expressed in this \npublication are those of the author(s) \nand do not necessarily reflect the views \nof the Department of Justice, Office on \nViolence Against Women. \nResources \nFlorida Council Against Sexual Violence \n1-888.956-7273 \nwww.fcasv.org \nVictim Compensation \n1-800-226-6667 \nwww.myfloridalegal.com \nFlorida Department of Law Enforcement \nSexual Offender/ Predator Unit \n1-888-357-7332; 1-850.410.8572 \nFor TTY Accessibility: 1-877-414-7234 \nE-mail: sexpred@fdle.state.fl.us \nFlorida Department of Corrections \nVictim Information and Notification Everyday \n(VINE) \n1-877-VINE-4-FL \nwww.dc.state.fLus/othivictasst/index.html \nFlorida Abuse Hotline \n1-800-962-2873 \nLocal Rape Crisis Center \nPalm Beach County Victim Services \n& Certified Rape Crisis Center \nVictim Services SART Center \n4210 North Australian Avenue \nWest Palm Beach, FL 33407 \nOffice: 561-625-2568 \nHelpline: 866-891-RAPE (7273) \nwww.pbcgov.com/publicsafety/ \nvictimservices \nAWN 2ol . 40:0 \nEFTA00006060\n\nCenter for Trauma Counseling \nWhere Your Emotional Healing Can Begin \nA non-profit Community Counseling Center \nServing Palm Beach County and beyond \nIndividual, Couples, Family, & Group Therapy \nServices for Children (3 y/o) to Adults (99 +) \nWe offer affordable counseling services to those that are insured and not insured. \nInsurance accepted: Cigna, Humana Commercial, Magellan, Beacon (Humana Medicaid, \nCoventry) \nSliding Scale: Reduced fees based on income for those who qualify \nLanguages Spoken: English, Spanish, and Farsi \nEvidence Based Models: Play/Sand Tray therapy, EMDR, Trauma Focused Cognitive Behavioral \nTherapy \nHours: Monday-Friday, Saturdays and evening appointments available \nReferral Process: Call 561-444-3914 (Office) email: info@palmbeachmentalhealth.org \nCenter for Trauma Counseling, Inc. \n6801 Lake Worth Road, Suite 307 \nGreenacres, FL 33467 \nOffice: 561-444-3914 \nwww.parrnbeachmentalhealth.org \nEFTA00006061\n\nOffice of the Attorney General \nThe Capitol. PL-01 • Tallahassee, FL 3230-1050 . Office: (800)2264687 Fax: (853) 414.6191 \nBill Status Inform:tier for Providers 050) 414-3331 • TDD users may call through Florida Relay Service at 1.803.9558771 \n'Nebsite: myfloridalegalcom • Email address: vointake@myfloridalegal.com \nBUREAU OF VICTIM COMPENSATION CLAIM FORM \nInstructions \nPlease read the Eligibility Requirements to see if you qualify for this program. Fill out this form completely (please print). attach all required \ndocumentation. and submit to the above address. I' you move or change your address. you are required to notify this office. \nCHECK THE TYPE Of VICTIM COMPENSATION BENEFITS YOU ARE REQUESTING: \nFl DISABILITY - compensation for the victim who suffered a Donnell cisatilty. \nI—I (Attach documentasn as cktined in Section 3.) \nEg\nWAGE LOSS - compensation fa the victm who lost wages due to crime related \nph \ninjuries (Math documentation as outlined in Section 3.) \nSS OF SUPPORT - compensation for the dependent(s) of a deceased victim \nwho was employed at the time of the crime. (Attach Cournentaticn as alined \nin Section 4.) \nEXPENSES • payment cc retnticrsenent on oehSt of the victim for cnme-retaed \nfuneral/burial, medical/dente treatment and mental health cornseing expenses: \nas well as aesoiptions, eyeglasses, dentures, ons prosthetic &Ake lost \ndamaged, or required because of \ncone. \n(Attach termed bels and receip \ntreatment/funeral \nO \nFUNERAL/BURIAL \nEDICALMENTAL \nNTAL HEALTWGRIEF \nTREATMENT \nCOUNSELING \nin EMERGENCY ASSISTANCE - relmtursement fu dixturnented wage bee and \nout-of-packet a/pauses related b da Came. (Attach receipts.) \nCHECK ALL OTHER TYPES OF 8 ENEFFS YOU ARE REOUESTNG: (Separate claim numbes we be assigned.) \nIn PROPERTY LOSS for an Wuh over the age of 60 or enabled adult ,attach \nproof \ndisabity pre( to the dab) of nine from a physician a the Social Security \nAdministraton) who suflered the loss of tamable serSOna: property, as the restlt \nof a criminal or delinquent act. Math a receipt of written estinate train a vendor \nor merchant identifying lie comparable replacement value. Compensabie items \nmist be identified by the law enforcement report \nIn SEXUAL BATTERY RELOCATION ASSISTANCE - for the vctm of sexual \nCelery seeking assstance b relocate due to reasonable fear A certified rape \ncrisis center certificatior form must be received with Ine appintion. \nSection 1. Victim and Applicant Information \nVICTIM'S NAME \n(lar. Net mcldle) \nSOCIAL \nSECURITY NO. \nADORE \nTELEPHONE \nNUMBER \nALTERNATE\nPHONE NUMBER \nTITS INFORMATION IS COLLECTED FOR FEDERAL REPORTING PURPOSES AND IS OPTIONAL. \nRAMETHINICEY CIMAERICAN 'MAW EIASLAN BLACIVATRICAN rl \nHISPANIC cr \nI--IkLASKA NATIVE \nI—I AMERICAN \nL.—I LATINC \n(- 1 DOMESTIC VIOLENCE RELOCATION ASSISTANCE - be the victim of \ndonestc violence seeking assistance to relocate to a sate environment. A \ncerifieo domesic violence certif talon form and applcaton nust be receved \nwith 33 days horn the date of crime. \nri \nHUMAN TRAFFICKING RELOCATION ASSISTANCE - for the vctiir of sexual \ntraffickng with an urgent need to relocate. A rape orals or domestic ‘iolence \ncerter cerbicaton fern and applicator] must be received within 45 days of the \nlast identifiable threat. \nCCCUPATICe gala wv-ety.r.va,A-\nO NATIVE HAWAIIAN or OTTER PACIFIC ISLANDER K \nOTHER RACE \nO eiLLTIRE RACES \nWHITE NONLKINOCAUCASIAN \nGENDER: ti \n!it \nThe applicant temp on peep* of a 'kern is required to provide clamant information below. When requestng compensation cn behalf of an incompetent adult victim prcol \nof legal guardianship must be attached, and the applicant's signature an tie dairr form must oe witnessed by a Notary Public. \nIS THE VICTIM icheo ore) \nDECEASED O INJURED MINOR \nK \nAl" INJ WITNESS" O INCOMPETENT \nNOT \nURED \nAPPLICANT NNE \nBed. first middle) \nDATE OF \nBIRTH \n/ \n/ \nSOCIAL \n' E-MAIL \nSECURITY NO. \nI ADDRESS \nWOULD YOU UKE ALL CORRESPONDENCE \nSENT BY EMAIL? \nYES \nNO \nADDRESS \nCITY \nSTATE \nZIP \nCODE \nTEL EPHosE / \nTAMER \nk \nALTERNATE \ni\nPHONE NUMSER k \nRELATIONSHIP \nTO vICTIM \nOCCUPATION \nNATIONAL ORIGIN \nlikS P1 \nWAS VICTIM DISABLED \nBEFORE THE CRIME OCCURRED? \nD YES \nEIVC lee Vt15) \nThe Mee of the Attorney General. Bureau of Victim Compensation is an equal opportunity provider and empasyer. \nPage 1 of it \nEFTA00006062\n\nSection 2. Referral Source Information \nIndividuals who assisted with or filled out any sections of this application are required to provide referral information below. By signing this applicatior, the victim/applicant \naffirms that all information provided is true and correct, and thus. al sections should be reviewed before the application is signed. (Treatment providers can request \ntraining on the Victim Compensation Program. which is recommended prior to becoming a referral source.) \nMME OF PERSON ASSISTING WITH APPLICATION \nI EMAIL \npast first mimic) \nADDRESS \nhAME OF AGENCY/ORGANIZATION \nAGENCY ORGANZATIONS ADDRESS \n(address. city, state, zip code) \nSection 3. Disability or Lost Wages Information \nMen westing ceneersatcrfor bst %vars.tech a copy ofyour ray stub or conics staterrynt atiich 'decrees you eTploinert stale WO wages ate tee d the CAM V)0ll ae Semple* \nor voider a trtiyrnenter, attach a spay of yet blest barna tax ream aril apckabe MS schedule tarns. If mot than 5 work days were meted as a rasa d the crime Malta &dors bear \nwtich erased you kr tag abseret When leclAstril dsatilY COMPenSaf011, alath a dactyls letter neon speaks each cite related penmen( cisabity rang exoreIng bleanest:an lAeckal \nAssoParn Gtitlekes ar Sktifia Imparrre7t Patric Gudekes. and favrad &oat SepolykInwasaatcr award leders \nELEPHQNE\nNUMBER\nSUPERVISOR'S WE \nliAl.E OF COMPANY/BUSINESS \nle we ban ere In ernotiyar,pkeie mach looms 'heel \nCONPAINY ADDRESS \nIaddress. city state, zip code) \nIS WAGE LOSS COVERED BY INSURANCE? \nLI YES \nIS WAGE LOSS COVERED BY WORKER'S COMPENSATION? I-1"° \nYES \nTELENCINIE\nWEER \n)\nNIJ \nIS VICTIM DISABLED AS A RESULT OF THE CRIME? \nn \nYES \nI I NO \nn NO \nSection 4. Loss of Support Information or Grief Counseling Information \n'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 attach a copy of the deceased victim's \n3t•eSI income tar rein and individual earnings statement reemploynont assistance benefit statement. tour rimer for support. birth mrtficate which idenbfies dependent \nviationship, marriage cerhficato, or legal documentation proving principal suapidt. \nDEPENDANTAUNCR CLAINAN- NAME(S) \nDATE OF BIRTH \nRELATIONSHIP TO MTN \nSection 5. Insurance Information \nClements who are determined eligible for the Vctim Compensation and Prcoerty Loss Program may be 'mem( Iran the irsurance deductble or co-payment provisions Of \ntheir insurance policyQes). \nIS INSURA.NCE OR MEDCAJD AVAILABLE TO ASSIST WITH THESE EXPENSES? \nO YES \nNO \nMEDICAID NUMBER \nyes, prende be foaming ix d inwrance paces. including lAerliceid Medicare. Flo hanoonnoq. ailomobit, or moice medal &tad as related insdarce Expknabcn Of Senses statardends). \ni COMPANY NAME \nAV-C (AM ilVt WAWA \nNUMBE \n0 - 40 \n- 115 - 258- 5 \nADDRESS \nCITY \nZIP \nCODE \n2. COMPANY NAME \nPOLICY NUMBER \nTELEPHONE/\nNUMBER \nADDRESS \nCITY \nSTATE \nZr \nCODE \nI TELEPHRONE/ \nSection 6. Other Compensation, Settlement, and Attorney Information \nYou must notify this off ce if ye/ have race yea or f yrn antapate receiving compensation or any benefits from any tithe source as a result of this inadent. You must also \nnotify this office if you have or are laming to hire an attorney to represert you as a result of the incident \nSTATE THE SOURCE AND \nDATE RECEIVED (IFAPFUCAN1) \n0 I ‘S-I t 41 \nI ARE YOU REPRESEN-ED_ / \nI \nBY LEGAL COUNSEL? L'\nS 0 NO \nATTORNEY'S NAME \nI \nADDRESS \nEMAIL \nADDRESS \nI TELEPHONE \nNUMBER \nCITY \nSTATE \nZIP \nCODE \n\\\nBY; 100 tits) \nThe Office of the Attorney General, Bureau of Victim Compensation is an equal oeportoney provider and employe, \nPogo 2 of 4 \nEFTA00006063\n\nSection 7. Crime Information \nThis section must be completed and proof of Crime (such as a law enforcement report a charging affidavit) must be attached. Failure to submit proof of crime wit result in \nyour application not being processed or your claim being denied. \nNAME OF LAW \nDATE OF \nCRIME \nI DATE REPORTED TO LAW \nENFORCEMENT AGENCY \nENFORCEMENT AGENCY \nWAS THE CRP& \nj\n \nREPORTED TO LAW ENFORCEMENT WITHIN 72 HOURS? \nYES \nONO \nIf no. please explain. (II no. failure to provide an acceptable explanation in this section will result in a denial of beneib.) \nIS THE APPLICATION AND LAW ENFORCEMENT REPORT BEING SUBMITTED WITHIN ONE YEAR FROM THE DATE OF CRIME? K YES 13 NO \nIf no, please explain. (Please be advised that most benefits apply to treatment losses suffered within one year from the date of crane. with sane exceptions for minor wan \nII no. Mime to Monde an %Made explanation in this seams MI result n a denial of bonen.) \nTYPE OF CRIME AS SPECIFIED \nON THE LAW ENFORCEMENT REPORT \nNAME OF LAW \nENFORCEMENT OFFICER \nNME OF ASSISTANT STATE ATTORNEY \nHANDLING THE CASE Of applicatle) \nLAW ENFORCEMENT \nREPORT NUMBER \nSection 8. Eligibility Requirements \nNAME OF OFFENDER \nNlmoitin) \nSTATE ATTORNEY! \nCLEW OF COURT CASE NUMBER (if appicable) \nAdditional qualification criteria. deadlines, and exceptions not listed may apply. \nVictim Compensation (VC): The victim must cooperate fuly with law enforcement officials, State Attorneys Office, and the Attorney General's Office. The clime \nmust be reported to law enforcement within 72 hours, unless there is good cause for delayed reporting. The claim must be filed Within one year after the date \nof the crime or within two years when there is good reason for not fling within one year. Exceptions for filing time requirements apply to victims who are minors. \nThe victim must not have engaged in an unlawful activity or contributed to the situation that brought about his or her own injury or death. The victim must have \nsuffered a physical, psychiatric, psychological injury, or death as a result of the crime. \nProperty Loss (PL): The victim must have suffered a substantial diminution in their quality of life from the loss of tangible personal property as the result of a \ncriminal or delinquent act. Property loss reimbursement is available up to $500 on any one claim and a lifetime maximum of $1,000 on all claims. \nDomestic Violence Relocation Assistance (DV): The victim must need immediate assistance to escape a domestic violence environment. The application must \nbe filed within 30 days after the domestic violence crime. Certification by a certified domestic violence center in the State of Florida is required. The victim must \nsubmit estimates, invoices, or receipts for interim lodging, housing, utility deposits, new cellular phone service, transportation, moving company expenses, or \nemergency food or clothing. \nRelocation for Victims of Sexual Battery (RS): The victim must need to relocate due to a reasonable fear for his or her safety. Certification by a certified rape \ncrisis center in the State of Florida is required. The victim must submit estimates, invoices, or receipts for interim lodging, housing, utility deposits, new cellular \nphone service. transportation, moving company expenses, or emergency food or clothing. \nHuman Trafficking Relocation Assistance (HT): The victim must have an urgent need to escape from an unsafe environment directly related to a sexual human \ntrafficking offense. Application must be received within 45 days of the last identifiable threat by a human trafficking offender. The identifiable threat must have \nbeen communicated with the proper authorities. Certification from a certified rape crisis or domestic violence center in the State of Florida is required. The victim \nmust submit estimates, invoices or receipts from interim lodging, housing, utility deposits, new cellular phone service, transportation, moving company expenses, \nor emergency food or clothing. \nCriminal History Record Check: In order for compensation to be considered, the victim or applicant must not have been confined or in custody in a county \na municipal facility; a state or federal correctional facility; or a juvenile detention commitment. Or assessment facility; adjudicated as a habitual felony offender. \nhabitual violent offender, or violent career criminal; or adjudicated of a forcible felony offense. \nNotice of Payment Limitations: The Bureau of Victim Compensation may provide financial assistance for eligible persons, but only after all other sources of \n. payment have been exhausted. Payments accepted by in-state providers on behalf of victims are considered payment-in-full per Florida Statute. Total victim \ncompensation benefits cannot exceed the maximum award amount determined by the current benefit payment schedule. Limits below the maximum may ipty to \nspecific benefits, which may be reduced without prior notice to the award recipient based on the availability of funding. \nAcceptable Proof of Crime: The Bureau of Victim Compensation does not make an independent judgment on whether a compensable crime occurred, but \ninstead relies on proof of crime from the proper authorities. Failure to provide acceptable documentation proving that a compensable crime occurred shall result \nin your application not being processed or your claim being denied. Acceptable documentation includes: a law enforcement report or charging affidavit from \na child protection team, law enforcement agency, state or prosecuting attorney. or the Department of Children and Families that affirms a compensable crime \noccurred; an indictment by a grand jury; an indictment by a prosecutor from a court of competent jurisdiction; a report from the United States Federal Bureau of \nInvestigation; or a Florida Department of Law Enforcement cybercrime investigator certification of a crime for purposes of Section 960.197, F.S. \nComplete Application Package: It is your responsibility to provide a complete application package which includes acceptable documentation proving that a \ncome occurred. If the department receives a report which is insufficient for proving that a compensable crime occurred, the application will be assigned a claim \nnumber and denied. Claim numbers assigned are not indicative of eligibility or denial. For assistance with collecting acceptable documentation. please contact \nyour local law enforcement agency, the agency where the crime was reported, the referral source, or your local State Attomey's Office. \nBVC 100 (7/15) \nThe Office of the Attorney General, Bureau of Victim Compensation is an equal opportunity provider and employer. \nPage 3 of 4 \nEFTA00006064\n\nPLEASE READ CAREFULLY AND SIGN THE FOLLOWING CERTIFICATIONS \nSection 9. \nCONFIDENTIALITY: If you are Ire victim of a sexual battery. aggravated chid abuse. aggravated stalking, harassment, aggravated battery, or domestic \nviolence. you have the rignt to have information about your home address and telephore number, employment address and telephone number, and your \npersonal assets, kept confidential for a period of five years. If you are the victim of any of these crimes, please mark one of the following statements. Your \nresponse will not affe the processing of your claim. \nI want the information to be confidential \nO \nI do NOT want the information to be confidential \nSERIOUS FINANCIAL HARDSHIP: I certify that I have a senous financial hardship because of crime-related expenses that cannot be paid by any other \nsource. \nPROPERTY LOSS CERTIFICATION: I eerily that the property in question belonged to the victim: that this loss adversely affects the victim's quality of life: \nthat there is no other source of reimbursement for this loss; and that replacement of the prope-ty would cause the claimant a serious financial hardship. \nRELEASE OF INFORMATION: I give permission to any hospital, doctor. dentist, mental health counselor, or other treatment provider, bankng triStrtution, \nsocial service agency, law enforcement agency. corrections agency, state attorney's office, inssance carrier, attorney or employer to give out information that \nis requested concerning any treatment rendered, employment Insurance thrd-party payer, or law enforcement nvestigative information to the Department \nof Legal Affairs for use in processing my dom. I give permission lo the Department to release information about the status of my claim to any treatment \nprovider, law enforcement agency. or state attorney's office. \nSOCIAL SECURITY NUMBER DISCLOSURE: The Bureau cf Victim Compensation collects and uses Social Security numbers for the purpose of performing \nmperatve duties and responsiNifieswtoch may include the forowing: searching criminal history records. identity management. biting and payments, benefit \nprocessing. and reporting to authorized state and federal government agencies. Failure to provide this optimal information may delay lhe processing of your \napplication or benefits. Federal and State laws fracture the Bureau to protect Social Security numbers from disclosure to ulauthoized parties. Absent a waiver \nfrom you or your legal representative Social Security numbers will be redacted. unless the agency receives a court order to turn over a ron redacted file. \nREPAYMENT REQUIREMENT: I understand that payment by the victim compensation program is a payment of last resort and that I must repay the Crimes \nCompensation Trust Fund if I receive a victim compensation award and also receive payment from another source as a result of the same crrninal incident \nOtter 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. \nI further understard that I must repay any emergency award from the Cnmes Compensation Trust Fund, If my claim is determined ineligible. I also understand \nthat if my eligibility is withdrawn, I must repay any amount received from the Crimes Compensation Trust Fund. \nAPPLICANT: Applcant signature is required if Mine as the parent. legal guardian. a individual authorized to administer a vctirts estate. \nPnnted Name: \nSignature: \nDate.\nUnder Penalty of Perjury or fraud, the information I have provided is true and correct to the best o' my knowledge. \nNOTARIZATION REQUIREMENT: Persons submitting an application on behalf of an incompetent adult must sibmit prin.,' or legal guarcianship \nand have their signalize mtnessed by a Notary Public. \nSworn to and subscribed oefore nit this \nday of \n. 20 \nPersonalty known to me. \nIdentification produced. \nVotary Pottle Signature: \nStamp/Seal: \nBVC 10i (-7/15) \nThe Office or the Attorney General, Bureau of Victim Compensation is en equal opportunity provider rid employer \nPage 4 of 4 \nEFTA00006065\n\n--- Page Break ---\n\nVision \nJustice for all crime victims. \nMission Statement \nWith compassion and respect, \nwe assist victims of sexual \nevil- et, domestic violence, \nhomicide, and other violent \ncrimes through crisis response, \nadvocacy, therapy, and \ncommunity awareness. \nPalm Beach County \nVictim Services \nis a Certified Rape Crisis Center \nthat provides therapy services to \nall crime victims in Palm Beach \nCounty regardless of the victims' \nrace, sex, color, religion, national \norigin, disability, sexual \norientation, marital status, \nfamilial status or gender identity \nor expression. \nStart by Believing: \nStart by \nr \nA Public Awareness \nBelieving \nCampaign to \nChange the Way \nWe Respond to Sexual Violence in Our \nCommunity... one response at a time. \nYOUR REACTION \nMAKES THE DIFFERENCE. \nWhen someone tells you they've \nbeen raped. there's a simple response. \nStart by Believing. \nkilo. \nit . tr.; \ncounty \nSafety .Department \njiiiedin Services Division\nwwwpbcgov.com/publitsafety/victimSeeVicett \n24/7 SEXUAL ASSAULT \nVIOLENT CRIME HELPLINE \nHELPLINE: (561 -8$3`7273 \nTOLL FREE: (866) 891.7273 \n1:.N \nEoi rehouse \n-'205 45itil Utile Hwy , Suite 5.1109 \nWest Palm Beach. FL 33401 \n(561) 355-2418 option 3 \nTTY: (561) 233-2595 \nVictim Services SART Center \n42113 North Australian Ave. \nVilest Palm Beach. FL 33407 \n(561)625.2568 option 1 \n• \nTIT (561) 6244520 \nNoith County Courthouse \n3188 PGA Blvd.. Suite 1436 \nPalm Beach Gardens, FL 33410: \n(561) 355-2418 option 3 \n' \n(561) 624.6643 \nSouth County Courthouse \n200. West lykraje Ave., Suitt E-301 \nDenyW4aeh. \n(50) 274:1500 \nITV: (561) 274-1015 \nes" \nWest County-Glades Courthouse \n2976 $tate n&d 15. 2nd Floor \nBelle Glade, FL 33430 \n(561) 996-4871 \nITV; (561)992-1113.._ -.-\n--Like Us on \nprzvictimsgrytces \nSart-gifts are funded through Palm Beachtounty Board of \nCounty Cornthissioners with grants fronithe OKI& of the - \nAttorpeyGeneral and Honda Council Against Sexual Violence;;.,-. \n-0, \nPalm tescItCounly \nN\nPalm Beach \nti \n• '. \n'Public Saki< Denali Intent \niclim Sci viucs Di% is io \nSewing Victims of Violent Crimes \n1 \nEFTA00006055\n\nHave You Been \n,. \nA Victim Of A Crime? \nDo' Thu Experience \nAny Of The Following? \n* Inability to fall orstay asleep? \n* Feeling anxious or depressed? \n* Having outbursts of anger? \n* Inability to concentrate? \n* reeling emotionally numb? \n* Loss of interest in the things you used to enjoy? \n* Painful memories of the traumatic event? \n* Bad dreams about the traumatic event? \n* flashbacks or a sense of reliving the events? \n* Racing thoughts? \n* Physiological stress response to reminders of the \nevent? (pounding heart, rapid breathing, nausea, \nmuscle tension, sweating) \nPalm Beach County provides equality of services and \ncare to everyone, regardless of people's age, disability. \ngender. gender identity, race, religion or belief or \nsexual orientation. \nFree services include individual therapy \nfor children and adults and adult-support \ngroups. \nIf you are a crime victim or have been \na victim of crime in the past and are \nconsidering therapy, we welcome your coll. \nTherapists are available for appointments \nMonday through Friday, excluding legal \nholidays. \nTherapists Will Help You: \nO Identify trauma reactions \nO Explore the impact that trauma has on your daily life \nO Reduce the intensity of negative emotional \nresponses and symptoms \nO Learn about common trauma reactions and \nphases in healing \nO Feel hopeful and positive regarding the future \nO Develop coping mechanisms to utilize when \nthinking or talking about the crime \nO Experience a reduction of trauma symptoms \nO Return to work or school \nO Explore the impact on current and future \nrelationships \nerapy For \nChildren & Teenagers \nO Assessment and treatment for child victims \nof crime\nO Therapeutic interventions that teach \nchild safety \n• \n.0 Play Therapy \n.0 Assistance for parents during this \ndifficult time \nSigns Of lPauma In Children \nO Sadness: The child may feel despondent or \nhopeless The child may cry easily or withdraw/ \nisolate from others. \nO Loss of interest in activities: The child may \ncomplain of feeling "bored" or reject offers to \nparticipate in activities they have previously \nenjoyed. \nO Anxiety: The child may become anxious and, \ntense, and feel panic. \nO Turmoil: The child may feel worried and \nirritable. The child may lash out in anger \nresulting from the distress he/she is feeling. \nO Regression: The child may revert to acting \nlike a baby. bedwetting, clinging and \ndemanding extra care. \nEFTA00006056\n\nVision \nJustice for all crime victims. \nMission Statement \nWith compassion and respect, we assist \nvictims of sexual assault, domestic violence, \nhomicide, and other violent crimes through \ncrisis response, advocacy, therapy, and \ncommunity awareness. \nFlorida Statute 960 Provides \nGuidelines For Fair lFeatment \n& Specific Rights For Victims \nIn The Criminal Justice System \nSome of these include the following: \nO Office of Attorney General Crime Victim \nCompensation, when applicable; \nO lb be informed, present, and heard, when \nrelevant at all crucial stages of criminal or \njuvenile proceedings, to the extent that right \ndoes not interfere with the Constitutional \nrights of the accused; \n0 lb be provided information concerning \nservices available including Victim \nCompensation, community treatment \npnagrams, crisis intervention services, \ncounseling and social services; \n0 lb a prompt and timely disposition of the case. \nto the extent that this right does not interfere \nwith the Constitutional rights of the accused; \n0- lb have your property returned to you as soon \nas possible after the investigation and/or \nprosecution is completed, unless there is a \ncompelling reason for its retention; \nO Have a Victim Advocate present during \ndepositions of the victim; \n0 Request, for specific crimes, an exemption \nprohibiting the disclosure of information to \nthe public which reveals your identification. \nPalm Beach County \nPublic Safety Department \nVictim Services Division \nwww.pbcgov.comipublicsafety/victimservices \n24/7 SEXUAL ASSAULT \nVIOLENT CRIME HELPLINE \nHELPLINE: (561) 833.7273 \nTOLL FREE: (866) 891.7273 \nMain Courthouse \n205 North Dixie Hwy., Suite 5.1100 \nWest Palm Beach, FL 33401 \n(561) 355-2418 option 3 \nTTY: (561) 233.2595 \nVictim Services SART Center \n4210 North Australian Ave. \nWest Palm Beach, FL 33407 \n(561) 625.2568 option 1 \nTTY: (561) 624.6520 \nNorth County Courthouse \n3188 PGA Blvd., Suite 1436 \nPalm Beach Gardens, FL 33410 \n(561) 355-2418 option 3 \nTTY: (561) 624.6643 \nSouth County Courthouse \n200 West Atlantic Ave., Suite 1E-301 \nDelray Beach. FL 33444 \n(561) 274.1500 \nTTY: (561) 274-1015 \nWest County-Glades Courthouse \n2976 State Road 15. 2nd Floor \nBelle Glade, FL 33430 \n(561) 996.4871 \nTTY: (561) 992-1113 \nServices are provided to all crime victims in Palm Beach \nCounty regardless of the victims' race, sex. color, religion. \nnational origin, disability, age, sexual orientation. marital \nstatus, or gender identity or expression. \nServices are funded through Palm Beach County Board of \nCounty Commissioners with grants from the Office of the \nAttorney General and Florida Council Against Sexual Violence. \nPalm Beach County \nBoard of County Commissioners \nN May 2015 \nlike Us on \nPISCVIcUrrtServices \nPalm Beach County \nPublic Safety Department \nVictim Services Division \nVictim Services \n& Certified \nRape Crisis Center \nServing Victims of Violent Crimes \nEFTA00006057\n\nSexual Assault \nDomestic Assault \nServices Provided \nProfessional butting and community \npresentations are also available. \nO. Information about Victims' rights \n4. 24-hour crisis response to hospitals, law \nenforcement agencies and crime scenes \n0 Sexual Assault Nurse Examiner (SANE) and a \nForensic Exam site ti The Butterfly House \n4 Sexual Assault Response Team (SART) \nto provide Victim-centered assistance \n-4 Criminal Justice advocacy and \ncourt accompaniment \n4 Assistance with filing State Crime \nVictim Compensation applications and \nRestraining Orders \nO Individual therapy and support groups \n0 Information and referral to community \nresources, including shelters and Legal Aid \nPalm Beach County provides equality of services and \ncare to everyone, regardless of people's age, disability. \ngender, gender identity, race, religion or belief or \nsexual orientation. \nSexual Assault is a violent crime including rape, \nincest, sexual harassment or any other sexual \ncontact without consent. \nPer Florida Statute 90.5035. a victim of sexual \nviolence who consults a sexual assault counselor at \na rape crisis center has the right to confidentiality of \ninformation shared with the counselor. \nNo one except the victim can compel the sexual \nassault counselor to reveal information about their \ncommunications. Only the victim can waive the \nprivilege, and this must be done in writing. \nIf rape victims are not sure whether to report to law \nenforcement, victim advocates will assist them \nthrough their decisionmaking process, respecting \nwhatever choices are made. \nCertified Rape Crisis Victim Advocates \nWill Provide: \n4 Crisis Intervention and Personal Advocacy \nAccompaniment during forensic rape exams at \nThe Butterfly House and other medical facilities \n0 Coordination of follow-up medical care, therapy \nand referrals \n4 Criminal Justice advocacy and court accompaniment \nStart by MS, \nBelieving \nStart by Believing: A Public \nAwareness Campaign to Change \nthe Way We Respond to Sexual \nViolence in Our Community... \none response at a time. \nYOUR REACTION MAKES THE DIFFERENCE. \nWhen someone tells you they've been raped. there's a \nsimple response. Start by Believing. \nDomestic Assault involves power and control \ntactics such as physical violence. emotional abuse, \nsexual violence, economic abuse, and isolation. \nVictim Advocates Will Provide: \nCrisis Intervention \n4 Safety Planning \n0 Assistance with filing Restraining Orders \n0 Safe-Shelter Referrals \n4 Personal and legal advocacy during \ncriminal justice proceedings \nHomicide and \nOther Violent Crimes \nHomicide and other violent crimes shatter the \nlives of injured victims and survivors causing \nsevere emotional trauma and grief. \nVictim Advocates Will Provide: \n4 Crisis Intervention and emotional support \nfor victims and surviving family members \n0 Assistance with filing crime victim \ncompensation for medical expenses. \nfuneral costs and loss of support \n4 Court Accompaniment \n4 Referrals for individual therapy, support \ngroups and community assistance \nEFTA00006058\n\nHelp is Available \nVictims of sexual crimes need \ncompassion, sensitivity and empathy. \nBeing the victim of a crime can be \noverwhelming. Your reactions are normal. \nLocal certified rape crisis centers have \nadvocates who are there to help all \nvictims, regardless of whether or not \nthey report to law enforcement. \nServices are free and confidential —\ncertified rape crisis centers are legally \nand ethically required to protect your \nconfidentiality, unless you allow, in \nwriting, the release of your information. \nAdvocates are available to: \n• Provide crisis intervention \n• Speak to you on the 24-hour hotline \n• Discuss your options \n• Navigate available resources \n• Go with you to appointments \n• Address safety concerns \n• Advocate on your behalf \n• Help you apply for victim compensation \nSexual Battery is a Crime! \nIn Florida, the legal term for rape or \nsexual assault is sexual battery (F.S. \n794.011). Sexual battery means oral, \nanal, or vaginal penetration by, or union \nwith, the sexual organ of another or the \nanal or vaginal penetration of another by \nany other object, committed without your \nconsent. \nConsent means Intelligent, knowing, \nand voluntary consent and does not \ninclude coerced submission. Failure to \noffer physical resistance to the \noffender does not imply consent. \nA person under 16 years of age \ncannot legally consent to sex. Also, a \nperson 24 years of age or older or a \nperson in a familial or custodial \nposition of authority cannot receive \nconsent from 16 and 17 year old \nminors. \nForensic Exam \nWhat is a forensic exam? \nThe forensic exam is a head-to-toe exam to collect \nevidence and check for injuries after a sexual crime. \nWhat are my rights with regard to the \nexam? \n• Stop the exam at any time \n• Have an advocate from a rape crisis center with \nyou \n• Be informed about the status of the kit during \nprocessing \nWhat evidence is collected? \nDuring the exam, the medical professional may collect \nblood, urine, saliva, pubic hair combings and/or nail \nsamples. They may also collect items of your clothing. \nThey will ask you questions about the crime and your \nmedical history in order to help them collect evidence. \nWhat happens to the evidence? \nIf you make a report to law enforcement, your kit will \nbe sent to the regional or statewide lab within 30 \ndays for testing. The lab is required to process the kit \nwithin 120 days. \nIf you don't report the crime to law enforcement at \nthe time you obtain the exam, your kit will be stored \nanonymously. Your kit may be stored for only a \nlimited time, depending on your community's storage \nspace. The local rape crisis center can advise you \nabout the storage timelines in your community. \nEFTA00006059\n\nYou have the right to: \n• Obtain a forensic exam whether or not you report \nto law enforcement \n• Have an advocate at the forensic exam with you \n• Have the forensic exam sent for testing within 30 \ndays, if reported to law enforcement \n• Review the law enforcement report prior to final \nsubmission \n• Be informed, present, and be heard at all crucial \nstages of the criminal or juvenile proceeding \n• Have an advocate with you during a discovery \ndeposition \n• Have identifying information about the criminal \ninvestigation kept confidential \n• Have the offender, if charged, tested for HIV and \nhepatitis \n• Attend sentencing or disposition of the offender \n• Notification of judicial proceedings and scheduling \nchanges \n• Notification about the release of incarcerated \noffender \n• Request restitution \n• Give a victim impact statement \n• Not be subjected to a polygraph \n• Take up to 3 days of leave from work (with eligible \nemployer) \n• Apply for an injunction if you fear for your safety or \noffender is nearing release \nVictim Compensation \nYou may be eligible for \nfinancial assistance for: \n• Medical Care \n• Lost Income \n• Mental health services \n• Relocation \n• Other expenses related to injuries as a result \nof the crime \nContact your local certified rape \ncrisis center for more information. \nThis project was supported by Grant \nNo. 2015-WL-AX-0037 awarded by \nthe Office on Violence Against Women, \nU.S. Department of Justice. The \nopinions, findings, conclusions, and \nrecommendations expressed in this \npublication are those of the author(s) \nand do not necessarily reflect the views \nof the Department of Justice, Office on \nViolence Against Women. \nResources \nFlorida Council Against Sexual Violence \n1-888.956-7273 \nwww.fcasv.org \nVictim Compensation \n1-800-226-6667 \nwww.myfloridalegal.com \nFlorida Department of Law Enforcement \nSexual Offender/ Predator Unit \n1-888-357-7332; 1-850.410.8572 \nFor TTY Accessibility: 1-877-414-7234 \nE-mail: sexpred@fdle.state.fl.us \nFlorida Department of Corrections \nVictim Information and Notification Everyday \n(VINE) \n1-877-VINE-4-FL \nwww.dc.state.fLus/othivictasst/index.html \nFlorida Abuse Hotline \n1-800-962-2873 \nLocal Rape Crisis Center \nPalm Beach County Victim Services \n& Certified Rape Crisis Center \nVictim Services SART Center \n4210 North Australian Avenue \nWest Palm Beach, FL 33407 \nOffice: 561-625-2568 \nHelpline: 866-891-RAPE (7273) \nwww.pbcgov.com/publicsafety/ \nvictimservices \nAWN 2ol . 40:0 \nEFTA00006060\n\nCenter for Trauma Counseling \nWhere Your Emotional Healing Can Begin \nA non-profit Community Counseling Center \nServing Palm Beach County and beyond \nIndividual, Couples, Family, & Group Therapy \nServices for Children (3 y/o) to Adults (99 +) \nWe offer affordable counseling services to those that are insured and not insured. \nInsurance accepted: Cigna, Humana Commercial, Magellan, Beacon (Humana Medicaid, \nCoventry) \nSliding Scale: Reduced fees based on income for those who qualify \nLanguages Spoken: English, Spanish, and Farsi \nEvidence Based Models: Play/Sand Tray therapy, EMDR, Trauma Focused Cognitive Behavioral \nTherapy \nHours: Monday-Friday, Saturdays and evening appointments available \nReferral Process: Call 561-444-3914 (Office) email: info@palmbeachmentalhealth.org \nCenter for Trauma Counseling, Inc. \n6801 Lake Worth Road, Suite 307 \nGreenacres, FL 33467 \nOffice: 561-444-3914 \nwww.parrnbeachmentalhealth.org \nEFTA00006061\n\nOffice of the Attorney General \nThe Capitol. PL-01 • Tallahassee, FL 3230-1050 . Office: (800)2264687 Fax: (853) 414.6191 \nBill Status Inform:tier for Providers 050) 414-3331 • TDD users may call through Florida Relay Service at 1.803.9558771 \n'Nebsite: myfloridalegalcom • Email address: vointake@myfloridalegal.com \nBUREAU OF VICTIM COMPENSATION CLAIM FORM \nInstructions \nPlease read the Eligibility Requirements to see if you qualify for this program. Fill out this form completely (please print). attach all required \ndocumentation. and submit to the above address. I' you move or change your address. you are required to notify this office. \nCHECK THE TYPE Of VICTIM COMPENSATION BENEFITS YOU ARE REQUESTING: \nFl DISABILITY - compensation for the victim who suffered a Donnell cisatilty. \nI—I (Attach documentasn as cktined in Section 3.) \nEg\nWAGE LOSS - compensation fa the victm who lost wages due to crime related \nph \ninjuries (Math documentation as outlined in Section 3.) \nSS OF SUPPORT - compensation for the dependent(s) of a deceased victim \nwho was employed at the time of the crime. (Attach Cournentaticn as alined \nin Section 4.) \nEXPENSES • payment cc retnticrsenent on oehSt of the victim for cnme-retaed \nfuneral/burial, medical/dente treatment and mental health cornseing expenses: \nas well as aesoiptions, eyeglasses, dentures, ons prosthetic &Ake lost \ndamaged, or required because of \ncone. \n(Attach termed bels and receip \ntreatment/funeral \nO \nFUNERAL/BURIAL \nEDICALMENTAL \nNTAL HEALTWGRIEF \nTREATMENT \nCOUNSELING \nin EMERGENCY ASSISTANCE - relmtursement fu dixturnented wage bee and \nout-of-packet a/pauses related b da Came. (Attach receipts.) \nCHECK ALL OTHER TYPES OF 8 ENEFFS YOU ARE REOUESTNG: (Separate claim numbes we be assigned.) \nIn PROPERTY LOSS for an Wuh over the age of 60 or enabled adult ,attach \nproof \ndisabity pre( to the dab) of nine from a physician a the Social Security \nAdministraton) who suflered the loss of tamable serSOna: property, as the restlt \nof a criminal or delinquent act. Math a receipt of written estinate train a vendor \nor merchant identifying lie comparable replacement value. Compensabie items \nmist be identified by the law enforcement report \nIn SEXUAL BATTERY RELOCATION ASSISTANCE - for the vctm of sexual \nCelery seeking assstance b relocate due to reasonable fear A certified rape \ncrisis center certificatior form must be received with Ine appintion. \nSection 1. Victim and Applicant Information \nVICTIM'S NAME \n(lar. Net mcldle) \nSOCIAL \nSECURITY NO. \nADORE \nTELEPHONE \nNUMBER \nALTERNATE\nPHONE NUMBER \nTITS INFORMATION IS COLLECTED FOR FEDERAL REPORTING PURPOSES AND IS OPTIONAL. \nRAMETHINICEY CIMAERICAN 'MAW EIASLAN BLACIVATRICAN rl \nHISPANIC cr \nI--IkLASKA NATIVE \nI—I AMERICAN \nL.—I LATINC \n(- 1 DOMESTIC VIOLENCE RELOCATION ASSISTANCE - be the victim of \ndonestc violence seeking assistance to relocate to a sate environment. A \ncerifieo domesic violence certif talon form and applcaton nust be receved \nwith 33 days horn the date of crime. \nri \nHUMAN TRAFFICKING RELOCATION ASSISTANCE - for the vctiir of sexual \ntraffickng with an urgent need to relocate. A rape orals or domestic ‘iolence \ncerter cerbicaton fern and applicator] must be received within 45 days of the \nlast identifiable threat. \nCCCUPATICe gala wv-ety.r.va,A-\nO NATIVE HAWAIIAN or OTTER PACIFIC ISLANDER K \nOTHER RACE \nO eiLLTIRE RACES \nWHITE NONLKINOCAUCASIAN \nGENDER: ti \n!it \nThe applicant temp on peep* of a 'kern is required to provide clamant information below. When requestng compensation cn behalf of an incompetent adult victim prcol \nof legal guardianship must be attached, and the applicant's signature an tie dairr form must oe witnessed by a Notary Public. \nIS THE VICTIM icheo ore) \nDECEASED O INJURED MINOR \nK \nAl" INJ WITNESS" O INCOMPETENT \nNOT \nURED \nAPPLICANT NNE \nBed. first middle) \nDATE OF \nBIRTH \n/ \n/ \nSOCIAL \n' E-MAIL \nSECURITY NO. \nI ADDRESS \nWOULD YOU UKE ALL CORRESPONDENCE \nSENT BY EMAIL? \nYES \nNO \nADDRESS \nCITY \nSTATE \nZIP \nCODE \nTEL EPHosE / \nTAMER \nk \nALTERNATE \ni\nPHONE NUMSER k \nRELATIONSHIP \nTO vICTIM \nOCCUPATION \nNATIONAL ORIGIN \nlikS P1 \nWAS VICTIM DISABLED \nBEFORE THE CRIME OCCURRED? \nD YES \nEIVC lee Vt15) \nThe Mee of the Attorney General. Bureau of Victim Compensation is an equal opportunity provider and empasyer. \nPage 1 of it \nEFTA00006062\n\nSection 2. Referral Source Information \nIndividuals who assisted with or filled out any sections of this application are required to provide referral information below. By signing this applicatior, the victim/applicant \naffirms that all information provided is true and correct, and thus. al sections should be reviewed before the application is signed. (Treatment providers can request \ntraining on the Victim Compensation Program. which is recommended prior to becoming a referral source.) \nMME OF PERSON ASSISTING WITH APPLICATION \nI EMAIL \npast first mimic) \nADDRESS \nhAME OF AGENCY/ORGANIZATION \nAGENCY ORGANZATIONS ADDRESS \n(address. city, state, zip code) \nSection 3. Disability or Lost Wages Information \nMen westing ceneersatcrfor bst %vars.tech a copy ofyour ray stub or conics staterrynt atiich 'decrees you eTploinert stale WO wages ate tee d the CAM V)0ll ae Semple* \nor voider a trtiyrnenter, attach a spay of yet blest barna tax ream aril apckabe MS schedule tarns. If mot than 5 work days were meted as a rasa d the crime Malta &dors bear \nwtich erased you kr tag abseret When leclAstril dsatilY COMPenSaf011, alath a dactyls letter neon speaks each cite related penmen( cisabity rang exoreIng bleanest:an lAeckal \nAssoParn Gtitlekes ar Sktifia Imparrre7t Patric Gudekes. and favrad &oat SepolykInwasaatcr award leders \nELEPHQNE\nNUMBER\nSUPERVISOR'S WE \nliAl.E OF COMPANY/BUSINESS \nle we ban ere In ernotiyar,pkeie mach looms 'heel \nCONPAINY ADDRESS \nIaddress. city state, zip code) \nIS WAGE LOSS COVERED BY INSURANCE? \nLI YES \nIS WAGE LOSS COVERED BY WORKER'S COMPENSATION? I-1"° \nYES \nTELENCINIE\nWEER \n)\nNIJ \nIS VICTIM DISABLED AS A RESULT OF THE CRIME? \nn \nYES \nI I NO \nn NO \nSection 4. Loss of Support Information or Grief Counseling Information \n'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 attach a copy of the deceased victim's \n3t•eSI income tar rein and individual earnings statement reemploynont assistance benefit statement. tour rimer for support. birth mrtficate which idenbfies dependent \nviationship, marriage cerhficato, or legal documentation proving principal suapidt. \nDEPENDANTAUNCR CLAINAN- NAME(S) \nDATE OF BIRTH \nRELATIONSHIP TO MTN \nSection 5. Insurance Information \nClements who are determined eligible for the Vctim Compensation and Prcoerty Loss Program may be 'mem( Iran the irsurance deductble or co-payment provisions Of \ntheir insurance policyQes). \nIS INSURA.NCE OR MEDCAJD AVAILABLE TO ASSIST WITH THESE EXPENSES? \nO YES \nNO \nMEDICAID NUMBER \nyes, prende be foaming ix d inwrance paces. including lAerliceid Medicare. Flo hanoonnoq. ailomobit, or moice medal &tad as related insdarce Expknabcn Of Senses statardends). \ni COMPANY NAME \nAV-C (AM ilVt WAWA \nNUMBE \n0 - 40 \n- 115 - 258- 5 \nADDRESS \nCITY \nZIP \nCODE \n2. COMPANY NAME \nPOLICY NUMBER \nTELEPHONE/\nNUMBER \nADDRESS \nCITY \nSTATE \nZr \nCODE \nI TELEPHRONE/ \nSection 6. Other Compensation, Settlement, and Attorney Information \nYou must notify this off ce if ye/ have race yea or f yrn antapate receiving compensation or any benefits from any tithe source as a result of this inadent. You must also \nnotify this office if you have or are laming to hire an attorney to represert you as a result of the incident \nSTATE THE SOURCE AND \nDATE RECEIVED (IFAPFUCAN1) \n0 I ‘S-I t 41 \nI ARE YOU REPRESEN-ED_ / \nI \nBY LEGAL COUNSEL? L'\nS 0 NO \nATTORNEY'S NAME \nI \nADDRESS \nEMAIL \nADDRESS \nI TELEPHONE \nNUMBER \nCITY \nSTATE \nZIP \nCODE \n\\\nBY; 100 tits) \nThe Office of the Attorney General, Bureau of Victim Compensation is an equal oeportoney provider and employe, \nPogo 2 of 4 \nEFTA00006063\n\nSection 7. Crime Information \nThis section must be completed and proof of Crime (such as a law enforcement report a charging affidavit) must be attached. Failure to submit proof of crime wit result in \nyour application not being processed or your claim being denied. \nNAME OF LAW \nDATE OF \nCRIME \nI DATE REPORTED TO LAW \nENFORCEMENT AGENCY \nENFORCEMENT AGENCY \nWAS THE CRP& \nj\n \nREPORTED TO LAW ENFORCEMENT WITHIN 72 HOURS? \nYES \nONO \nIf no. please explain. (II no. failure to provide an acceptable explanation in this section will result in a denial of beneib.) \nIS THE APPLICATION AND LAW ENFORCEMENT REPORT BEING SUBMITTED WITHIN ONE YEAR FROM THE DATE OF CRIME? K YES 13 NO \nIf no, please explain. (Please be advised that most benefits apply to treatment losses suffered within one year from the date of crane. with sane exceptions for minor wan \nII no. Mime to Monde an %Made explanation in this seams MI result n a denial of bonen.) \nTYPE OF CRIME AS SPECIFIED \nON THE LAW ENFORCEMENT REPORT \nNAME OF LAW \nENFORCEMENT OFFICER \nNME OF ASSISTANT STATE ATTORNEY \nHANDLING THE CASE Of applicatle) \nLAW ENFORCEMENT \nREPORT NUMBER \nSection 8. Eligibility Requirements \nNAME OF OFFENDER \nNlmoitin) \nSTATE ATTORNEY! \nCLEW OF COURT CASE NUMBER (if appicable) \nAdditional qualification criteria. deadlines, and exceptions not listed may apply. \nVictim Compensation (VC): The victim must cooperate fuly with law enforcement officials, State Attorneys Office, and the Attorney General's Office. The clime \nmust be reported to law enforcement within 72 hours, unless there is good cause for delayed reporting. The claim must be filed Within one year after the date \nof the crime or within two years when there is good reason for not fling within one year. Exceptions for filing time requirements apply to victims who are minors. \nThe victim must not have engaged in an unlawful activity or contributed to the situation that brought about his or her own injury or death. The victim must have \nsuffered a physical, psychiatric, psychological injury, or death as a result of the crime. \nProperty Loss (PL): The victim must have suffered a substantial diminution in their quality of life from the loss of tangible personal property as the result of a \ncriminal or delinquent act. Property loss reimbursement is available up to $500 on any one claim and a lifetime maximum of $1,000 on all claims. \nDomestic Violence Relocation Assistance (DV): The victim must need immediate assistance to escape a domestic violence environment. The application must \nbe filed within 30 days after the domestic violence crime. Certification by a certified domestic violence center in the State of Florida is required. The victim must \nsubmit estimates, invoices, or receipts for interim lodging, housing, utility deposits, new cellular phone service, transportation, moving company expenses, or \nemergency food or clothing. \nRelocation for Victims of Sexual Battery (RS): The victim must need to relocate due to a reasonable fear for his or her safety. Certification by a certified rape \ncrisis center in the State of Florida is required. The victim must submit estimates, invoices, or receipts for interim lodging, housing, utility deposits, new cellular \nphone service. transportation, moving company expenses, or emergency food or clothing. \nHuman Trafficking Relocation Assistance (HT): The victim must have an urgent need to escape from an unsafe environment directly related to a sexual human \ntrafficking offense. Application must be received within 45 days of the last identifiable threat by a human trafficking offender. The identifiable threat must have \nbeen communicated with the proper authorities. Certification from a certified rape crisis or domestic violence center in the State of Florida is required. The victim \nmust submit estimates, invoices or receipts from interim lodging, housing, utility deposits, new cellular phone service, transportation, moving company expenses, \nor emergency food or clothing. \nCriminal History Record Check: In order for compensation to be considered, the victim or applicant must not have been confined or in custody in a county \na municipal facility; a state or federal correctional facility; or a juvenile detention commitment. Or assessment facility; adjudicated as a habitual felony offender. \nhabitual violent offender, or violent career criminal; or adjudicated of a forcible felony offense. \nNotice of Payment Limitations: The Bureau of Victim Compensation may provide financial assistance for eligible persons, but only after all other sources of \n. payment have been exhausted. Payments accepted by in-state providers on behalf of victims are considered payment-in-full per Florida Statute. Total victim \ncompensation benefits cannot exceed the maximum award amount determined by the current benefit payment schedule. Limits below the maximum may ipty to \nspecific benefits, which may be reduced without prior notice to the award recipient based on the availability of funding. \nAcceptable Proof of Crime: The Bureau of Victim Compensation does not make an independent judgment on whether a compensable crime occurred, but \ninstead relies on proof of crime from the proper authorities. Failure to provide acceptable documentation proving that a compensable crime occurred shall result \nin your application not being processed or your claim being denied. Acceptable documentation includes: a law enforcement report or charging affidavit from \na child protection team, law enforcement agency, state or prosecuting attorney. or the Department of Children and Families that affirms a compensable crime \noccurred; an indictment by a grand jury; an indictment by a prosecutor from a court of competent jurisdiction; a report from the United States Federal Bureau of \nInvestigation; or a Florida Department of Law Enforcement cybercrime investigator certification of a crime for purposes of Section 960.197, F.S. \nComplete Application Package: It is your responsibility to provide a complete application package which includes acceptable documentation proving that a \ncome occurred. If the department receives a report which is insufficient for proving that a compensable crime occurred, the application will be assigned a claim \nnumber and denied. Claim numbers assigned are not indicative of eligibility or denial. For assistance with collecting acceptable documentation. please contact \nyour local law enforcement agency, the agency where the crime was reported, the referral source, or your local State Attomey's Office. \nBVC 100 (7/15) \nThe Office of the Attorney General, Bureau of Victim Compensation is an equal opportunity provider and employer. \nPage 3 of 4 \nEFTA00006064\n\nPLEASE READ CAREFULLY AND SIGN THE FOLLOWING CERTIFICATIONS \nSection 9. \nCONFIDENTIALITY: If you are Ire victim of a sexual battery. aggravated chid abuse. aggravated stalking, harassment, aggravated battery, or domestic \nviolence. you have the rignt to have information about your home address and telephore number, employment address and telephone number, and your \npersonal assets, kept confidential for a period of five years. If you are the victim of any of these crimes, please mark one of the following statements. Your \nresponse will not affe the processing of your claim. \nI want the information to be confidential \nO \nI do NOT want the information to be confidential \nSERIOUS FINANCIAL HARDSHIP: I certify that I have a senous financial hardship because of crime-related expenses that cannot be paid by any other \nsource. \nPROPERTY LOSS CERTIFICATION: I eerily that the property in question belonged to the victim: that this loss adversely affects the victim's quality of life: \nthat there is no other source of reimbursement for this loss; and that replacement of the prope-ty would cause the claimant a serious financial hardship. \nRELEASE OF INFORMATION: I give permission to any hospital, doctor. dentist, mental health counselor, or other treatment provider, bankng triStrtution, \nsocial service agency, law enforcement agency. corrections agency, state attorney's office, inssance carrier, attorney or employer to give out information that \nis requested concerning any treatment rendered, employment Insurance thrd-party payer, or law enforcement nvestigative information to the Department \nof Legal Affairs for use in processing my dom. I give permission lo the Department to release information about the status of my claim to any treatment \nprovider, law enforcement agency. or state attorney's office. \nSOCIAL SECURITY NUMBER DISCLOSURE: The Bureau cf Victim Compensation collects and uses Social Security numbers for the purpose of performing \nmperatve duties and responsiNifieswtoch may include the forowing: searching criminal history records. identity management. biting and payments, benefit \nprocessing. and reporting to authorized state and federal government agencies. Failure to provide this optimal information may delay lhe processing of your \napplication or benefits. Federal and State laws fracture the Bureau to protect Social Security numbers from disclosure to ulauthoized parties. Absent a waiver \nfrom you or your legal representative Social Security numbers will be redacted. unless the agency receives a court order to turn over a ron redacted file. \nREPAYMENT REQUIREMENT: I understand that payment by the victim compensation program is a payment of last resort and that I must repay the Crimes \nCompensation Trust Fund if I receive a victim compensation award and also receive payment from another source as a result of the same crrninal incident \nOtter 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. \nI further understard that I must repay any emergency award from the Cnmes Compensation Trust Fund, If my claim is determined ineligible. I also understand \nthat if my eligibility is withdrawn, I must repay any amount received from the Crimes Compensation Trust Fund. \nAPPLICANT: Applcant signature is required if Mine as the parent. legal guardian. a individual authorized to administer a vctirts estate. \nPnnted Name: \nSignature: \nDate.\nUnder Penalty of Perjury or fraud, the information I have provided is true and correct to the best o' my knowledge. \nNOTARIZATION REQUIREMENT: Persons submitting an application on behalf of an incompetent adult must sibmit prin.,' or legal guarcianship \nand have their signalize mtnessed by a Notary Public. \nSworn to and subscribed oefore nit this \nday of \n. 20 \nPersonalty known to me. \nIdentification produced. \nVotary Pottle Signature: \nStamp/Seal: \nBVC 10i (-7/15) \nThe Office or the Attorney General, Bureau of Victim Compensation is en equal opportunity provider rid employer \nPage 4 of 4 \nEFTA00006065