EFTA01699895

Vision Justice for all crime victims. Mission Statement With compassion and respect, we assist victims of sexual evil- et, domestic violence, homicide, and other violent crimes through crisis response, advocacy, therapy, and community awareness. Palm Beach County Victim Services is a Certified Rape Crisis Center that provides therapy services to all crime victims in Palm Beach County regardless of the victims' race, sex, color, religion, national origin, disability, sexual orientation, marital status, familial status or gender identity or expression. Start by Believing: Start by r A Public Awareness Believing Campaign to Change the Way We Respond to Sexual Violence in Our Community... one response at a time. YOUR REACTION MAKES THE DIFFERENCE. When someone tells you they've been raped. there's a simple response. Start by Believing. kilo. it . tr.; county Safety .Department jiiiedin Services Division wwwpbcgov.com/publitsafety/victimSeeVicett 24/7 SEXUAL ASSAULT VIOLENT CRIME HELPLINE HELPLINE: (561 -8$3`7273 TOLL FREE: (866) 891.7273 1:.N Eoi rehouse -'205 45itil Utile Hwy , Suite 5.1109 West Palm Beach. FL 33401 (561) 355-2418 option 3 TTY: (561) 233-2595 Victim Services SART Center 42113 North Australian Ave. Vilest Palm Beach. FL 33407 (561)625.2568 option 1 • TIT (561) 6244520 Noith County Courthouse 3188 PGA Blvd.. Suite 1436 Palm Beach Gardens, FL 33410: (561) 355-2418 option 3 ' (561) 624.6643 South County Courthouse 200. West lykraje Ave., Suitt E-301 DenyW4aeh. (50) 274:1500 ITV: (561) 274-1015 es" West County-Glades Courthouse 2976 $tate n&d 15. 2nd Floor Belle Glade, FL 33430 (561) 996-4871 ITV; (561)992-1113.._ -.- --Like Us on przvictimsgrytces Sart-gifts are funded through Palm Beachtounty Board of County Cornthissioners with grants fronithe OKI& of the - AttorpeyGeneral and Honda Council Against Sexual Violence;;.,-. -0, Palm tescItCounly N Palm Beach ti • '. 'Public Saki< Denali Intent iclim Sci viucs Di% is io Sewing Victims of Violent Crimes 1 EFTA01699895 Have You Been A Victim Of A Crime? Da You Experience Any Of The Following? * Inability to fall orstay asleep? * Feeling anxious or depressed? * Having outbursts of anger? * Inability to concentrate? * Feeling emotionally numb? * Loss of interest in the things yourpsed to enjoy? * Painful memories of the traumatic event? * Bad dreams about the traumatic event? * Flashbacks or a sense of reliving the events? * Racing thoughts? * Physiological stress response to reminders of the event? (pounding heart, rapid breathing. nausea. muscle tension, sweating) OMNI l'Af' ;PC Palm Beach County provides equality of services and care to everyone, regardless of peoples age, disability, gender, gender identity, race, religion or belief or sexual orientation. ces Provided . Free services include individual therapy for children and adults and adult-support groups. If you are a crime victim or have been a victim of crime in the past and are considering therapy, we welcome your call. Therapists are available for appointments Monday through Friday, excluding legal holidays. Therapists Will Help You: O Identify trauma reactions O Explore the impact that trauma has on your daily life • Reduce the intensity of negative emotional responses and symptoms O Learn about common trauma reactions and phases in healing O Feel hopeful and positive regarding the future O Develop coping mechanisms to utilize when thinking or talking about the crime O Experience a reduction of trauma symptoms O Return to work or school O Explore the impact on current and future relationships erapy For Children & Teenagers O Assessment and treatment for child victims of crime O Therapeutic interventions that teach child safety O Play Therapy O Assistance for parents during this difficult time Signs Of 'Mama In Children O Sadness: The child may feel despondent or hopeless The child may cry easily or withdraw/ isolate from others. O Loss of interest in activities: The child may complain of feeling "bored" or reject offers to participate in activities they have previously enjoyed. O Anxiety: The child may become anxious and, tense, and feel panic. O Turmoil: The child may feel worried and irritable. The child may lash out in anger resulting from the distress he/she is feeling. O Regression: The child may revert to acting like a baby. bedwetting, clinging and demanding extra care. EFTA01699896 Vision Justice for all crime victims. Mission Statement With compassion and respect, we assist victims of sexual assault, domestic violence, homicide, and other violent crimes through crisis response, advocacy, therapy, and community awareness. Florida Statute 960 Provides Guidelines For Fair lFeatment & Specific Rights For Victims In The Criminal Justice System Some of these include the following: O Office of Attorney General Crime Victim Compensation, when applicable; O lb be informed, present, and heard, when relevant at all crucial stages of criminal or juvenile proceedings, to the extent that right does not interfere with the Constitutional rights of the accused; 0 lb be provided information concerning services available including Victim Compensation, community treatment pnagrams, crisis intervention services, counseling and social services; 0 lb a prompt and timely disposition of the case. to the extent that this right does not interfere with the Constitutional rights of the accused; 0- lb have your property returned to you as soon as possible after the investigation and/or prosecution is completed, unless there is a compelling reason for its retention; O Have a Victim Advocate present during depositions of the victim; 0 Request, for specific crimes, an exemption prohibiting the disclosure of information to the public which reveals your identification. Palm Beach County Public Safety Department Victim Services Division www.pbcgov.comipublicsafety/victimservices 24/7 SEXUAL ASSAULT VIOLENT CRIME HELPLINE HELPLINE: (561) 833.7273 TOLL FREE: (866) 891.7273 Main Courthouse 205 North Dixie Hwy., Suite 5.1100 West Palm Beach, FL 33401 (561) 355-2418 option 3 TTY: (561) 233.2595 Victim Services SART Center 4210 North Australian Ave. West Palm Beach, FL 33407 (561) 625.2568 option 1 TTY: (561) 624.6520 North County Courthouse 3188 PGA Blvd., Suite 1436 Palm Beach Gardens, FL 33410 (561) 355-2418 option 3 TTY: (561) 624.6643 South County Courthouse 200 West Atlantic Ave., Suite 1E-301 Delray Beach. FL 33444 (561) 274.1500 TTY: (561) 274-1015 West County-Glades Courthouse 2976 State Road 15. 2nd Floor Belle Glade, FL 33430 (561) 996.4871 TTY: (561) 992-1113 Services are provided to all crime victims in Palm Beach County regardless of the victims' race, sex. color, religion. national origin, disability, age, sexual orientation. marital status, or gender identity or expression. Services are funded through Palm Beach County Board of County Commissioners with grants from the Office of the Attorney General and Florida Council Against Sexual Violence. Palm Beach County Board of County Commissioners N May 2015 like Us on PISCVIcUrrtServices Palm Beach County Public Safety Department Victim Services Division Victim Services & Certified Rape Crisis Center Serving Victims of Violent Crimes EFTA01699897 Sexual Assault Domestic Assault Services Provided Professional training and community presentations are also available. * Information about Victims' rights <> 24-hour crisis response to hospitals, law enforcement agencies and crime scenes 4 Sexual Assault Nurse Examiner (SANE) and a Forensic Exam site a, The Butterfly House 4 Sexual Assault Response Team (SART) a, to provide Victim-centered assistance 4- Criminal justice advocacy and court accompaniment 4 Assistance with filing State Crime Victim Compensation applications and Restraining Orders 0 Individual therapy and support groups 4 Information and referral to community resources, including shelters and Legal Aid Palm Beach County provides equality of services and care to everyone. regardless of people's age, disability, gender, gender identity, race, religion or belief or sexual orientation. Sexual Assault is a violent crime including rape, incest, sexual harassment or any other sexual contact without consent. Per Florida Statute 90.5035, a victim of sexual violence who consults a sexual assault counselor at a rape crisis center has the right to confidentiality of information shared with the counselor. No one except the victim can compel the sexual assault counselor to reveal information about their communications. Only the victim can waive the privilege, and this must be done in writing. If rape victims are not sure whether to report to law enforcement. victim advocates will assist them through their decisionmaking process. respecting whatever choices are made. Certified Rape Crisis Victim Advocates Will Provide: Crisis Intervention and Personal Advocacy * Accompaniment during forensic rape exams at The Butterfly House and other medical facilities 4 Coordination of follow-up medical care, therapy and referrals 4 Criminal Justice advocacy and court accompaniment Start by Iss Start by Believing: A Public Awareness Campaign to Change -- the Way We Respond to Sexual Believing Violence in Our Community.. one response at a time. YOUR REACTION MAKES THE DIFFERENCE. When someone tells you they've been raped. there's a simple response. Start by Believing. Domestic Assault involves power and control tactics such as physical violence, emotional abuse, sexual violence, economic abuse, and isolation. Victim Advocates Will Provide: Crisis Intervention Safety Planning 4 Assistance with filing Restraining Orders Safe-Shelter Referrals 4 Personal and legal advocacy during criminal justice proceedings Homicide and Other Violent Crimes Homicide and other violent crimes shatter the lives of injured victims and survivors causing severe emotional trauma and grief. Victim Advocates Will Provide: 4 Crisis Intervention and emotional support for victims and surviving family members Assistance with filing crime victim compensation for medical expenses, funeral costs and loss of support 4 Court Accompaniment 4 Referrals for individual therapy, support groups and community assistance EFTA01699898 Victims of sexual crimes need compassion, sensitivity and empathy. Being the victim of a crime can be overwhelming. Your reactions are normal. Local certified rape crisis centers have advocates who are there to help all victims, regardless of whether or not they report to law enforcement. Services are free and confidential — certified rape crisis centers are legally and ethically required to protect your confidentiality, unless you allow, in writing, the release of your information. Advocates are available to: • Provide crisis intervention • Speak to you on the 24-hour hotline • Discuss your options • Navigate available resources • Go with you to appointments • Address safety concerns • Advocate on your behalf • Help you apply for victim compensation In Florida, the legal term for rape or sexual assault is sexual battery (F.S. 794.011). Sexual battery means oral, anal, or vaginal penetration by, or union with, the sexual organ of another or the anal or vaginal penetration of another by any other object, committed without your consent. Consent means Intelligent, knowing, and voluntary consent and does not include coerced submission. Failure to offer physical resistance to the offender does not imply consent. A person under 16 years of age cannot legally consent to sex. Also, a person 24 years of age or older or a person in a familial or custodial position of authority cannot receive consent from 16 and 17 year old minors. What is a forensic exam? The forensic exam is a head-to-toe exam to collect evidence and check for injuries after a sexual crime. What are my rights with regard to the exam? • Stop the exam at any time • Have an advocate from a rape crisis center with you • Be informed about the status of the kit during processing What evidence is collected? During the exam, the medical professional may collect blood, urine, saliva, pubic hair combings and/or nail samples. They may also collect items of your clothing. They will ask you questions about the crime and your medical history in order to help them collect evidence. What happens to the evidence? If you make a report to law enforcement, your kit will be sent to the regional or statewide lab within 30 days for testing. The lab is required to process the kit within 120 days. If you don't report the crime to law enforcement at the time you obtain the exam, your kit will be stored anonymously. Your kit may be stored for only a limited time, depending on your community's storage space. The local rape crisis center can advise you about the storage timelines in your community. EFTA01699899 You have the right to: • Obtain a forensic exam whether or not you report to law enforcement • Have an advocate at the forensic exam with you • Have the forensic exam sent for testing within 30 days, if reported to law enforcement • Review the law enforcement report prior to final submission • Be informed, present, and be heard at all crucial stages of the criminal or juvenile proceeding • Have an advocate with you during a discovery deposition • Have identifying information about the criminal investigation kept confidential • Have the offender, if charged, tested for HIV and hepatitis • Attend sentencing or disposition of the offender • Notification of judicial proceedings and scheduling changes • Notification about the release of incarcerated offender • Request restitution • Give a victim impact statement • Not be subjected to a polygraph • Take up to 3 days of leave from work (with eligible employer) • Apply for an injunction if you fear for your safety or offender is nearing release Victim Compensation You may be eligible for financial assistance for: • Medical Care • Lost Income • Mental health services • Relocation • Other expenses related to injuries as a result of the crime Contact your local certified rape crisis center for more information. This project was supported by Grant No. 2015-WL-AX-0037 awarded by the Office on Violence Against Women, U.S. Department of Justice. The opinions, findings, conclusions, and recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the Department of Justice, Office on Violence Against Women. Resources Florida Council Against Sexual Violence 1-888.956-7273 www.fcasv.org Victim Compensation 1-800-226-6667 www.myfloridalegal.com Florida Department of Law Enforcement Sexual Offender/ Predator Unit 1-888-357-7332; 1-850.410.8572 For TTY Accessibility: 1-877-414-7234 E-mail: [email protected] Florida Department of Corrections Victim Information and Notification Everyday (VINE) 1-877-VINE-4-FL www.dc.state.fLus/othivictasst/index.html Florida Abuse Hotline 1-800-962-2873 Local Rape Crisis Center Palm Beach County Victim Services & Certified Rape Crisis Center Victim Services SART Center 4210 North Australian Avenue West Palm Beach, FL 33407 Office: 561-625-2568 Helpline: 866-891-RAPE (7273) www.pbcgov.com/publicsafety/ victimservices AWN 2ol . 40:0 EFTA01699900 Center. for Trauma Counseling Where Your Emotional Healing Can Segin A non-profit Community Counseling Center Serving Palm Beach County and beyond Individual, Couples, Family, & Group Therapy Services for Children (3 y/o) to Adults (99 +) We offer affordable counseling services to those that are insured and not insured. Insurance accepted: Cigna, Humana Commercial, Magellan, Beacon (Humana Medicaid, Coventry) Sliding Scale: Reduced fees based on income for those who qualify Languages Spoken: English, Spanish, and Farsi Evidence Based Models: Play/Sand Tray therapy, EMDR, Trauma Focused Cognitive Behavioral Therapy Hours: Monday-Friday, Saturdays and evening appointments available Referral Process: Call 561-444-3914 (Office) email: [email protected] Center for Trauma Counseling, Inc. 6801 Lake Worth Road, Suite 307 Greenacres, FL 33467 Office: 561-444-3914 www.palmbeachmentalhealth.org EFTA01699901 Office of the Attorney General The Capitol. PL-01 • Tallahassee, FL 32399-1050 • Office! (800) 226-6657 Fax: (850) 414-6191 Bill Status Information for Providers 1850) 414-3331 • TOD users may call through Florida Relay Service at 1.803-955.8771 Website: myfloridategal.com • Email address: [email protected] BUREAU OF VICTIM COMPENSATION CLAIM FORM Instructions Please read the Eligibility Requirements tc see if you qualify for this program. Fill out this form completely (please print). attach all requred documentation. and submit to the above addross. If you move or change your address. you are required to notify this office. CHECK THE TYPE OF VICTIM COMPENSATION BENEFITS YOU ARE REQUESTING: I—I DISABILITY - compensation for tie victim who suffered a permanent disability. I—I / (Attach documentation as outlined in Section 3.) WAGE LOSS - compensation for the victm who lost wages due to crime related ph sal Injuries (Attach documentation as outlined in Section 3.) SS OF SUPPORT - compensation for the dependent(s) of a deceased victim who was employed at the time of the crime. Attach decunentatico as outlined in Section 4.) EXPENSES - payment a reimbursement on *mil of the victm for cnme-retared ICJ funeral-burial. medicaPdental treatment and mental heath comsehng expenses: as well as prespiptions, eyeglasses, dentures, or a prosthetic deice lost i wi damaged, r required because of crime. (Attach tamed his and mei freatmentluneral or idea.) FUNERAUBURIAL ED e ZICAUDEN-AL NTAL HEALTH/GRIEF TREATMENT COUNSELING In EMERGENCY ASSISTANCE • reimbursement ty documented wage loss and l---I out-of-packet expenses related lo the aims. Attach motets i CHECK ALL OTHER TYPES OF BENEFITS YOU ARE REQUESTING: (Separate claim numbers MI be assq red.) ri PROPERTY LOSS for an *dull over the age of DO adisabled adult !attach proof o' disability prow to the dale of crime from a physician or die Social Security Administraton) who sufered the loss of tang ble "mom; property as the result of a criminal or delinquent act. Mach a receipt or written estimate from a venter or merchant identifying tie comparable replacement value. Compensable items must be idenfiGed by the le* enforcement report El SEXUAL BATTERY RELOCATION ASSISTANCE • tor the vCOM of sexual " battery seating assatance b repeat des to reasonable tear A certified rape crisis center certification form must to received wAh he application. Section 1. Victim and Applicant Information VICTIM'S NAME Oat fait, middle) SOCIAL SECURITY NO. ADORE TELEPHONE NUMBER ALTERNATE PHONE NUMBER oath TY Pc..kmfSecAch ri DOMESTIC VIOLENCE RELOCATION ASSISTANCE - by the victim of domestc violen:e seeking assistance to relocate to a sate ervironment A cease domestic violence certification farm and applcaton must be receved within 33 days from the date of cnme. CI HUMAN TRAFFICKING RELOCATION ASSISTANCE • 'or the victim of sexual trending with an urgent need to relocate. A raps cats or dynastic violence center cervicaton form and apckaton must be received within 45 days of the last identifiable threat DATE0 MTN ULD YOU MEAL. CCRRESPCNDENCE NT BY EMAIL? ISSYES El NO STATE ft— cote 35401 INS INFORMATION IS COLLECTED FOR FEDERAL REPORTING PURPOSES AND IS OPTIONAL FLAMETHINICrY: rIAMERICAN WM ❑ASIAN I—I 8LACKA ICAN❑ HISPANIC 0 "ALASKANATIVE L--IAMEHRAN LJ LANNC GENDER ine Fec, The applicant filing on behalf cf a victim is required to pretide claimant information below. When recNeStng compensation cn behat of an incompetent adult victim, proof of legal guardianship must be attached, and the applicants signature on the claim form must be witnessed by a Notary Public. NATIONAL ORIGIN LAS OCCUPATION it( ‘a.a cAL eh O NATIVE HAWAIIAN°. ODER PACIFICISLANDER K OTNERRACE PeWHITENOIELKINOCAVCASIAN K MULTIPLE RACES WAS VCTIN DISABLED BEFORE THE CRIME OCCURRED? K YES Elm) IS THE WOW Idea one) O DECEASED K INJURED MINOR APPLICANT NAME (last first ?riddle) DATE OF MTH / / SOCIAL SECURfRY NO. Emil ADDRESS WOULD YOU LIKE ALL CORRESPONDENCE SENT BY EMAIL? K YES K NO ADDRESS CITY STATE ZIP CODE TE.EPHONE NUNIRFR ( ) ALTERNATE i PHCNE NUV3ER k ) RELATIONSHIP TO VICTIM OCCUPATION I—I AIINCR WITNESS- K i4COLIESTEVI NOT IN.AIRED BVC 100 (ma) TN Office of flue ArThrney Ganaral. Bureau of Victim Comperestion is an equal opportunity provider end employer. Page 1 of 4 EFTA01699902 Section 2. Referral Source Information IndividuaS w41O assisted with or Stied out any sections of this application we required to provide referral information below. By siring this apolicatior, the victim/applicant affirms Vat el informaticn provided is true and correct and thus, all sections should be reviewed before the application is signed. (Treatment providers can request training on the Vctim Compensation Program. which is recommended prior to becoming a refaral source.) NAME OF PERSON ASSISTING WITH APPLICATION E-MAIL pest fast middle) ADDRESS MME OF AGENCWORGANIZATICN AGENCY.ORGANIZARONS ADDRESS !_address. Qty. stalk rip code) Section 3. Disability or Lost Wages Information When respestng conigensaden brbst wages.adath a cm of you' pay stub cc awnings statement whthdentifies youemployment slats at woes at the Ire of Iheoime. lyou aeselfenployed cr wok fa a fariy member, attach a cep/ of your blest income tax ram and amicable IRS scteduie tires. I more than Swart dais was missal as a retold te &ere aladiadooter's better which exasee you for tae ateerce. Men reliesthg deabitycompereatn. adapt a dada's Neer Mich species ea& thme tad pamment disabity rating axoning b reAmerica-I Medcar Assoiaim Giideines Ebriga Irrpliment Ring GAM% affected Social Scarily Admrestator award letters TELEPHONE NUM3ER SUPERVISOR'S NAIIE RAW OF COMPANY/BUSINESS el we sun ere Ill emptier. pima emch wagons sheen COWART ADDRESS ieuiress, Oty, crab. Bp code) S WAGE LOSS COVERED BY INSURANCE? LI YES NO S VtAGE LOSS COVERED BY WORKER'S COMPENSATION? YES TELEPHONE ) NJMEER IS VICTIM DISABLED AS A RESULT OF THE CFdME7 YES 11 NO n NO Section 4. Loss of Support Information or Grief Counseling Information Micate the narrets'd and date(s) of both of the deceasec victro's surviving spouse, parent. s toting, 0' chid. For loss of support anach a cop/ of the deceased vitro's :Meet income tax return and individual earnings statement reemployment assistance benefit statement cour, orcer for support, tail certficae which deities dependent elation-ship, manage certificate or legal documentation proving princi,pa support DEPENDANT/MINCR CLAMANT NAME(S) DATE OF BIRTH RELATIONSHIP TO viCTLi Section 5. Insurance Information Clements who are determined eligible for the Vaim Compensation and Rooerty Loss Programs may be exempt him the insurance deductible or co-payment provisions of their insurance oolicy(ies). IS INSURANCE OR MEDOND AVAILABLE TOASSIST WITH THESE MENSES? O YES ID NO MEDICAID NUMBER: It yes. promo ow Mimeos or al mumse pokier. ock(Ong Idedcaid Medan, He. horiecvinces. (Amebic, ormajor nrdinl Arach ell related instate &planation of )melt. sistcment(5). t. CO"ANir: (fit% bfi- h•C tka TELEPHONE/ _ 09 - '1 l S. 2 s t 5 KAMER {I . ADDRESS CITY ZIP CODE 2. COWANY NAME ADDRESS POLICY NUMBER CITY STATE TELEPHONE( NUMBER k ZIP CODE Section 6. Other Compensation, Settlement and Attorney Information You must notify this office if you have race vect or 1 you anticipate receiving compensation or any benefits from any other source as a result of this hitident You must also notify this office if you have or are planning to lire an attorney to represent you as a result of the ncident ( PPJCABLE) kOk i BY LEGAL COJNSEL? t al I ME YOU REPRESENTED AEso S O NO ATTORNEYS DATE RECEIVED IF A STATE THE SOURCE AND ADDRESS EMAIL ADDRESS CITY STATE ZIP CCOE 1 TELEPHONE NUMBER BV: 1 CO (7,15) The Off‘o cf the Attdroty Goners!, Bureau of Victim Compensation is an OqUal opportunity provider and empopy. Page 2 of EFTA01699903 Section 7. Crime Information This section must be completed and proof of crime (such as a law enforcement report or charging affidavit) must be attached Failure to submit proof of crime wit result in your application not being processed or your claim being denied. NAME OF LAW DATE CF I DATE REPORTED TO LAW ENFORCEMENT AGENCY CRIME I ENFORCEMENT AGENCY WAS THE CRIME REPORTED TO LAW ENFORCEMENT WITHIN 72 HOURS? ❑YES K NO If no. please explain. DI no. fates to provide an acceptable exolanaton in this sedan wia result in a (rental of benefits.) IS THE APPUCATIONAND LAW ENFORCEMENT REPORT BEING SUBMITTED WITHIN ONE YEAR FROM THE DATE Cf CRIME? El YES K NO If no. please explain (Passes be advised that most benefits apply to treatment losses suffered watts one year from the date of crime. win some exceptions for mina Saint If no, failure to provide an acceptable explanation in this sector wi result steamed of benefits.) TYPE OF CRIME AS SPECFIED ON THE LAW ENFORCEMENT REPORT NAME OF LAW ENFORCEMENT OFFICER NAME OF ASSISTANT STATE ATTORNEY HANDLING THE CASE (d apflcSe) LAW ENFORCEMENT REPORT NUMBER Section 8. Eligibility Requirements Addifional qua cation criteria, deadlines. and exceptions not listed may apply. Victim Compensation (VC): The victim must cooperate fury with law enforcement officials, State Attorneys Office, and the Attorney Generals Office. The crime must 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 of the crime or within two years when there is good reason for not filing within one year. Exceptions for filing time requirements apply to victims who are minors. The 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 suffered a physical, psychiatric, psychological injury, or death as a result of the crime. Property 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 criminal or delinquent act. Property loss reimbursement is available up to $500 on any one claim and a lifetime maximum of 51,000 on all claims. Domestic Violence Relocation Assistance (DV): The victim must need immediate assistance to escape a domestic violence environment. The application must be 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 submit estimates, invoices, or receipts for interim lodging, housing, utility deposits, new cellular phone service, transportation, moving company expenses, or emergency food or clothing. Relocation 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 crisis center in the State of Florida is required. The victim must submit estimates, invoices, or receipts for interim lodging, housing, utility deposits, new cellular phone service, transportation, moving company expenses, or emergency food or clothing. Human Trafficking Relocation Assistance (HT): The victim must have an urgent need to escape from an unsafe environment directly related to a sexual human trafficking offense. Application must be received within 45 days of the last identifiable threat by a human trafficking offender. The identifiable threat must have been communicated with the proper authorities. Certification from a certified rape crisis or domestic violence center in the State of Florida is required. The victim must submit estimates, invoices or receipts from interim lodging, housing, utility deposits, new cellular phone service, transportation, moving company expenses, or emergency food or clothing. Criminal 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 or municipal facility; a state or federal correctional facility; or a juvenile detention commitment, or assessment facility; adjudicated as a habitual felony offender, habitual violent offender, or violent career criminal; or adjudicated of a forcible felony offense. Notice of Payment Limitations: The Bureau of Victim Compensation may provide financial assistance for eligible persons, but only after all other sources of payment have been exhausted. Payments accepted by in-state providers on behalf of victims are considered payment-in-full per Florida Statute. Total victim compensation benefits cannot exceed the maximum award amount determined by the current benefit payment schedule. Limits below the maximum may apply to specific benefits, which may be reduced without prior notice to the award recipient based on the availability of funding. Acceptable Proof of Crime: The Bureau of Victim Compensation does not make an independent judgment on whether a compensable crime occurred, but instead relies on proof of crime from the proper authorities. Failure to provide acceptable documentation proving that a compensable crime occurred shall result in your application not being processed or your claim being denied. Acceptable documentation includes: a law enforcement report or charging affidavit from a chid protection team, law enforcement agency, state or prosecuting attorney, or the Departrnent of Children and Families that affirms a compensable crime occurred; 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 Investigation; or a Florida Department of Law Enforcement cybercrirne investigator certification of a crime for purposes of Section 960.197, F.S. Complete Application Package: It is your responsibility to provide a complete application package which includes acceptable documentation proving that a crime occurred. If the department receives a report which is insufficient for proving that a compensable crime occurred, the application will be assigned a claim number and denied. Claim numbers assigned are not indicative of eligibility or denial For assistance with collecting acceptable documentation. please contact your local law enforcement agency. the agency where the crime was reported, the referral source, or your local State Attorney's Office. BVC 100 (7115) The Office of the Attorney General, Bureau of Victim Compensation is an equal opportunity provider and employer. Page 3 of 4 NAME OF OFFENDER (if kern) STATE ATTORNEY/ CLERK OF COURT CASE NUMBER (rf appkable) EFTA01699904 PLEASE READ CAREFULLY AND SIGN THE FOLLOWING CERTIFICATIONS Section 9. CONFIDENTIALITY: If you we the victim of a sexual battery, aggravated child abuse, aggravated stalking, harassment aggravated tatteiy, or domestic violence. you have the right to have information about your home address and telephone number, employment address and telephone number, and your personal 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 response will not affeft the processing of your claim. I want the information to be confidential El I do NOT want the information to be confidential SERIOUS FINANCIAL HARDSHIP: I credit/ that I have a serous financal hardship because of crime-related expenses that cannot be paid by any other source. PROPERTY LOSS CERTIFICATION: I cerify that the property in question belonged to the victim: that this loss adversely affects the victim's quality of lire: that thee is no other source of reimbursement 'or this 'oss: and that replacement of the property would cause the claimant a serious financial hardship. RELEASE OF INFORMATION: I give permission to any nospital, doctor. dentist, mental health counselor, or other treatment 0rovider, bankng institution. social service agency, law enforcement agenCy. COyections agency, state attorney's office, insurance earner, attorney or employer to give out information that is requested concerning any treatment rendered, employment insurance. third-party payer, or law enforcement investigative information to the Department of Legal Affairs for use in processing my claim. I give permission to the Department to release information about the status of my claim to any treatment provider, law enforcement agent/. or state attorneys office. SOCIAL SECURITY NUMBER DISCLOSURE: The Bureau of Victim Compensation collects and uses Social Security numbers for the purpose of performing mperatve duties and 'esponsibilities which may include the following: searching criminal history records, identity management, billing and payMents, benefit processing and reporting to authorized state and federal government agencies. Failure to provide this optional information may delay me processing of your application or benefits. Federal and State laws require the 3ureau to protect Social Seventy numbers from disclosure to unauthorized parties. Absent a waiver from 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. REPAYMENT REQUIREMENT: I understand that payment by the victim compensation program is a payment of last resort and that I must repay the Crimes Compensation Trust Fund if I receive a victim compensation award and alto receive payment from another source as a result of the same criminal Incident Other 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. I further understand that I must repay any emergency award from the Crmes Compensation Trust Fund, if my claim is determined ineligible. I also understand that if my eligibility is withdrawn, I must repay any amount received Nom the Crimes Compensation Trust Fund. APPLICANT: Appicant signature is required if fling as the parent. legal guardian, or individual authorized to administer a vctlri's estate. Pnnted Name: Signature: Date: Under penalty of perjury or fraud, the irlormation I have provided is true and correct to the best of my knowledge. NOTARIZATION REQUIREMENT: Persons submitting an application on behatt of an ncompetern adult must submit prod of legal guarcianship and have their signature witnessed ty a Notary Public. Sworn to and subscribed Defore me this day of . 20 Personally known to me. O Identification produced. Notary Public Signature: Stamp/Seal: BYC 100 (7/15) The Office of the Attorney Central, Bureau of Victim Compensation is en n04 opponuniy provider and employer Page a of 4 EFTA01699905