Vision
Justice for all crime victims.

Mission Statement
With compassion and respect,
we assist victims of sexual
assanlt, domestic violence,
homicide, and other violent
crimes through crisis response,

Start by Believing:
Start by 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 hy Believing.

By FAR LC TTY: (561) 992-1113...

a Seyices afe funded th rough Palm Bedch “County Board of
“County Commissioners with grants from the Office of the -
ae General and Bofida Council Against Sexual Violen

WWW, shed compublcsafeyeimsenicess.

24/7 SEXUAL ASSAULT ~~
"VIOLENT CRIME HELPLINE
" HELPLINE: (561) 833-7273
TOLL FREE: 869) 891-7273

7 ee = Main Golirthouse eT
“505 North Dixie Hwy., Suite 5.1100
West Palm Beach, FL 33401 :

TTY: (561) 233-2595 a)

Victim Services SART Center ~~

4210 North Australian: AVBy=. oa

West Palm Beach, FL 33407 :

Jr (561)625-2568 option T ~~ =
ER TTY: (561) 624-6520

Tr

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
- Delf} Beach, FL'3%444 a
(561) 274-1500
TTY: (561) 274-1015

West County-Glades Courthouse
2976 State Road 15, 2nd Floor
Belle Glade, FL 33430
TT (561) 996-4871

- =

[al irc

(561) 355-2418 option 3 a

alm Beach Courts

i

I"
LI

Public Satety” Department
{ia

Servives Division

EFTA00006055


"A Victim Of A Crime?

Do’ You Experience
‘Any Of The Following?

* Inability to fall or stay asleep?

# Feeling anxious or depressed?

*¥ Having outbursts of anger?

* Inability to concentrate?

%* Feeling emotionally numb?

# Loss of interest in the things you used 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)

ef — i

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.

es Provided.

Ne Services include by Mp
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:

4 Identify trauma reactions
% Explore the impact that trauma has on your daily life

%# Reduce the intensity of negative emotional
responses and symptoms

% Learn about common trauma reactions and
phases in healing

# Feel hopeful and positive regarding the future

4% Develop coping mechanisms to utilize when
thinking or talking about the crime

4 Experience a reduction of trauma symptoms
4% Return to work or school

4% Explore the impact on current and future
relationships

Children & Teenagers

# Assessment and treatment for child victims |
of crime

# Therapeutic interventions that teach
child safety

4 Play Therapy

© Assistance for parents during this
difficult time

Signs Of Trauma In Children

+ Sadness: The child may feel despondent or
hopeless. The child may cry easily or withdraw/
isolate from others.

4 Loss of interest in activities: The child may
complain of feeling “bored” or reject offers to
participate in activities they have previously
enjoyed.

# Anxiety: The child may become anxious and, |
tense, and feel panic.

# Turmeil: The child may feel worried and
irritable. The child may lash out in anger
resulting from the distress he/she is feeling.

4 Regression: The child may revert to acting
like a baby, bedwetting, clinging and
demanding extra care.

EFTA00006056



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 Treatment
& Specific Rights For Victims
In The Criminal Justice System

Some of these include the following:

4 Office of Attorney General Crime Victim
Compensation, when applicable;

+ To 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;

“+ To be provided information concerning
services available including Victim
Compensation, community treatment
programs, crisis intervention services,
counseling and social services;

4 To a prompt and timely disposition of the case,
to the extent that this right does not interfere
with the Constitutional rights of the accused;

+ To have your property returned to you as soon
as possible after the investigation andlor
prosecution is completed, unless there is a
compelling reason for its retention;

+ Have a Victim Advocate present during
depositions of the victim;

+ 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.com/publicsafety/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

Public Sofety Department
Victim Services Division

Victim Services
& Certified

Rape Crisis Center

Serving Victims of Violent Crimes

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Services Provided

Professional training and community
presentations are alse 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 ~ The Butterfly House

+ Sexual Assault Response Team (SART) ~
to provide Victim-centered assistance

< Criminal Justice advocacy and
court accompaniment

< Assistance with filing State Crime
Victim Compensation applications and
Restraining Orders

% Individual therapy and support groups

+ Information and referral to community
resources, including shelters and Legal Aid

AT 1! a ~ =

Falm 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.

=

Na

Sexual Assault

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:

4 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

< Criminal Justice advocacy and court accompaniment

Start by Believing: A Public

Start by Awareness Campaign to Change

Sr 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.

f. Se iil

Domestic Assault

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
+ Assistance with fling Restraining Orders
+ Safe-Shelter Referrals

+ 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:
+ 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
< Court Accompaniment

< Referrals for individual therapy, support
groups and community assistance

EE

.

EFTA00006058


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

Sexual Battery is a Crime!

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?

= Slop 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 tesling. 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

EFTA00006059


Victim Bill of Rights

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

um 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 safely 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.

L_Besourcas J

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: sexpred@fdie.state.fl.us

Florida Department of Corrections
Victim Information and Notification Everyday
(VINE)

1-877-VINE-4-FL
www.dc.state.fl.us/oth/victasst/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 Z

4210 North Australian Avenue
West Palm Beach, FL 33407
Office: 561-625-2568
Helpline: 866-891-RAPE (7273) |
www.pbcgov.com/publicsafety/ \
victimservices f

March 3017 - 4000)

EFTA00006060


1 Center for Trauma Counseling

Vithere Your Emotional Healing Can Eegin

f

ra
NE)

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: info@palmbeachmentalhealth.org

Center for Trauma Counseling, Inc.
6801 Lake Worth Road, Suite 307
Greenacres, FL 33467
Office: 561-444-3914
www.palmbeachmentalhealth.org

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Office of the Attorney General

The Capitol, PL-01 + Tallahassee, FL 12369-1050 ® Office: (800) 226-6687 Fax: (B50) 414-6197
Bill Status Information for Providers (850) 414-3331 ® TDD users may call through Florida Relay Service at 1-800-855-8771
Website: myfloridalegal.com * Email address. veintake@myfloridalegal.com

BUREAU OF VICTIM COMPENSATION CLAIM FORM

Instructions
Please read the Eligibility Requirements to see if you qualify for this program. Fill out this form completely (please print), attach all required
documentation, and submit to the above address. If you move or change your addrass, you are required to notify this office.

CHECK THE TYPE OF VICTIM COMPENSATION BENEFITS YOU ARE REQUESTING:

Is DISABILITY - compensation for the victim who suffered a permanent disability. EXPENSES - payment or reimbursement on behalf of the victm for crime-relaed
{Attach documentation as outlined in Section J.) funeralfburial, medicalidenta treatment, and mental health counseling expanses;
WAGE LOSS - compensation for the victm who bst wages due to crime related robe cn pl ale nhl
physical injuries. (Attach documentation as cullined in Section 3.) (Attach femizad bills and recei \ ; Wuneral providers.)
§5 OF SUPPORT - compensation for the dependent(s) of a deceased victim CJ FUNERAL/EURIAL DICALIDENTAL AL HEALTH/GRIEF
who was employed at the time of the crime, (Aftach documentation as oulined TREATMENT COUNSELING
in Section 4.) EMERGENCY ASSISTANCE - reimbursement for documented wage loss and

out-of-pocket expenses relaled bb the crime. [Attach receipts.
CHECK ALL OTHER TYPES OF BENEFITS YOU ARE REQUESTING: {Separate claim numbes wil be assigned.)

ll PROPERTY LOSS - for an adult over the age of 50 or disabled adult (attach [] pomssmc VIOLENCE RELOCATION ASSISTANCE - for the victim of
proof of disability prio to the date of crime from a physician or the Social Security domestic vislence seeking assistance to relocate to a safe environment. A

Administration) who suflered the loss of tangible personal property &s the result certified domestic violence certifcation form and application must be receved

of a criminal or dedinquent act. Attach a receipt or writin estimate from a vendor within 30 days from the date of crime.

or mercharit identifying the comparable replacement value. Com nsable lems

must be identified by the law enforcement report. Sa [] HUMAN TRAFFICKING RELOCATION ASSISTANCE - for the victim of sexual
trafficking with an urgent need lo relocate. A rapa crisis or domestic viclence

baflery seeking assistance b relocate due (o reasonable fear. A certified rape las! identifiable threat.

crisis canter certification form must be received with the application

Section 1. Victim and Applicant Information

VICTIM'S MAME

(last, first, middle)
SOCIAL LD YOU LIKE ALL CORRESPONDENCE
SECURITY NO. NT BY EMAILT
CITY STATE IP
Norn Pram Bain | FL coe 35 40
ALTERNATE OCCUPATION
PHONE NUMBER ( ) Ea) Waneg: ma .

THIS INFORMATION IS COLLECTED FOR FEDERAL REPORTING PURPOSES AND IS OPTIONAL. L] NATIVE HAWAIIAN or OTHER PACIFIC ISLANDER EA OTHER RACE

RACEETHINICITY: [Juesucm INDRANY [Jaw £] BLACK/AFRICAN HISPANIC or
ALASKA NATIVE AMERICAN LATING RA wire MON-LATING/CAUCASIAN E+] MULTIPLE RACES
GENDER: NATIONAL ORIGIN WAS VICTIM DISABLED ve
m) iv WS A BEFORE THE GRIME OCCURRED? [] ves NO

The applicant fling on behalf of a victim is required to provide claimant information below. When requesting compensation on behalf of an incompetent aduft vielam, proof
of legal guardianship must be attached, and the applicant's signature on he claim form must be witnessed by a Notary Public.

IS THE VICTIM jcheck one) [] oecesen [] muuren mor = MINOR WITNESS - ] INCOMPETENT

NOT INJURED
APPLICANT NAME DATE OF
(last. first, icicle) BIRTH /
SOCIAL | EMAL WOULD YOU LIKE ALL CORRESPONDENCE
SECURITY NO. | ADDRESS SENT BY EMAIL? Cvs [Jw
ADDRESS city STATE Fl |
CODE
TELEPHONE ALTERNATE | RELATIONSHIP OCCUPATION
nar ( ) PHONE NUMBER ) TOVICTIM
BVC 100 (THE) The Office of the Attorney General, Bureau of Victim Compensation is an equal opportunity provider and employer Page 10f 4

A

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Section 2. Referral Source Information
ndividuats who assisted with or flied out any sections of this application are required to provide referral information below. By signing this application, the vicim/applicant
affirms that all information provided is true and correct, and thus, all sections should be reviewed before the application is signed. (Treatment providers can request
training on the Victim Compensation Program, which is recommandad prior to becoming a referral source. |

NAME OF PERSON ASSISTING WITH APPLICATION E-MAIL

(last, first, middle) ADDRESS

NAME OF AGENCY/ORGANIZATION

AGENCYIORGANZATIONS ADDRESS TELEPHONE )
(address, city, state, zip pode) HUMBER

Section 3. Disability or Lost Wages Information

Tre rosie comeemaion or ot wages, ach 8 copy of your pay sub or earings saement which dete your entpoyment siais and wages a i ime of he rie. yo re sek employed
cr work for a family member, attach a copy of your latest income tax eum and applicable IRS schedule forms. F more than 5 work days were missed as a result of the crime, attach a doctor's lefier
which axrused you for fis absence. When requesing dsabiity compensation, altach a doctor's letier which specifies each cme related panmanent disability rating according to he American Medical
Lssoriaicn Guidelines or Florida Impainment Rating Guidelines, and forward Social Security Administration award lefiers.

NAME OF COMPANYBUSINESS
{ more an one [1] employer, please atiach additiaal shee
COMPANY ADDRESS

, city, stale, Zip code
1S WAGE LOSS COVERED BY INSURANCE? YES NO 15 VICTIM DISABLED AS A RESULT OF THE CRIME? YES [1 NO
IS WAGE LOSS COVERED BY WORKER'S COMPENSATION? YES | [I] NO

Section 4. Loss of Support Information or Grief Counseling Information

indicate the name(s) and date(s) of birth of the deceased vichim's surviving spouse, parent, sibling, or child. For bes of support, attach a copy of the deceased victim's
latest income tax return and individual eamings statement, reemployment assistance benefit statement, court order for support, birth certficate which identifies dependent
relationship, marriage certificate, or legal documentabon proving principal support.

DEPENDANT/MINCR CLAIMANT NAME(S) DATE OF BIRTH RELATIONSHIP TO WCTIM

Section 5. Insurance Information
Samants who are determined eligible for the Vichm Compensalion and Property Loss Programs may be exempt from he insurance deductible or co-payment provisions of

IS INSURANCE OR MEDICAID AVAILABLE TO ASSIST WITH THESE EXPENSES? [J Yes [1 no MEDICAID NUMBER:
It yes, provid the following for all insurance policies, including Wedicesd, Medicare, Wo, homeowner's, automabila, or major medical Atach ol related insurance Explanation of Benefits statement(s).

POPPIN Less ive Sad — EEO) - 115 - 2563
ADDRESS CITY

2. COMPANY NAME POLICY NUMEER ail )
NUMBER

ADDRESS CITY STATE Fao

Section 6. Other Compensation, Settlement, and Attorney Information
You must notify this office ff you have received, or if you anticipate receiving compensation or any benefits from any other source as a result of this incident. You must also
nofify this office if you have or are planning to hire an atiomey to represent you as a result of the incident.

STATE THE SOURCE AND | ARE YOU REPRESENTED js
DATE RECEIVED grapruciny)  \D 1 \S | 4] BY LEGAL COUNSEL? [wo
ADDRESS E-MAIL
os " ADDRESS
CITY STATE [ZIP TELEPHONE
| CODE NUMBER
BVC 100 (THY) The Office of the Attorney General, Bureau of Victim Compensation is an equal opportunity provider and employe: Page 2 of 4

EFTA00006063



Section 7. Crime Information
THis sodlion must be completed and proof of crime (such as a law enforcement report or charging affidavil) must be attached. Failure to submit proof of crime will result in

your application not being processed of your claim being denied.

NAME OF LAW DATE OF DATE REPORTED TO LAW
ENFORCEMENT AGENCY CRIME ENFORCEMENT AGENCY
WAS THE CRIME REPORTED TO LAW ENFORCEMENT WITHIN 72 HOURS? YES NO

If no, please explain. (i no, failure to provide an acceptable explanation in this section will result in a denial of benefits.)

oe —

IS THE APPLICATION AND LAW ENFORCEMENT REPORT BEING SUBMITTED WITHIN ONE YEAR FROM THE DATE OF criMe? [J YES LINO
If no, please explain. (Please be advised that most benefits apply to treatment losses suffered within one year from the date of crime, with some excaplions for minor victims.
If no, failure to provide an acceptable explanation in this section will result in a denial of benefits.)

TYPE OF CRIME AS SPECIFIED LAW ENFORCEMENT

ON THE LAW ENFORCEMENT REPORT REPORT NUMBER

NAME OF LAW NAME OF OFFENDER

ENFORCEMENT OFFICER rawr

NAME OF ASSISTANT STATE ATTORNEY ihe ATTORNEY!

HANDLING THE CASE (i applicable) CLERK OF COURT GASE NUMBER (if applicable]

Section 8. Eligibility Requirements

‘Additional qualification criteria, deadlines, and exceptions not listed may apply.

Victim Compensation (VC): The victim must cooperate fully with law enforcement officials, State Attorney's Office, and the Attorney General's Office. The crime
must be reported to law enforcement within 72 hours, unless there is good cause for delayed reporting. The claim must be fled witin one year after fhe dae

Tf the crime or within two years when there is good reason for not ling within one year. Exceptions for fling time requirements apply to victims who are FEIOfS.
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 $1,000 on all claims.

Domestic Violence Relocation Assistance (DV): The victin must need immediate assistance to escape a domestic violence environment. The application must
be filed within 30 days afer the domestic violence crime. Certification by certified domestic violence center in the State of Florida is required. The victim must
submit estimates, invoices, of receipts for interim lodging, housing, utility deposits, new cellular phone service, transportation, moving company expenses, of
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
ists center in the State of Florida is required. The victim must submit estimates, invoices, or receipts for interim lodging, housing, uly deposits, new cellar
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
heen 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, utity deposits, new cellular phone service, iransportation, 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; " state or federal comedtional facility; or a juvenile detention commilment, or assessment facility; adjudicated as a habitual felony offence,
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 afte all other sources of

. payment have been exhausted. Payments accepted by in-state i on behalf of victims are considered payment-in-full per Florida Statute. Total victim

Fompensation benefits cannot exceed the maximum award amount determined by the current benefit payment schedule. Limits below the maximum may 2p ©
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 child tection team, law enforcement agency, stat or prosecuting attomey, of the Department of Children and Families that affims 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; o a Florida Department of Law Enforcement cybercrime investigator ceriication of a crime for purposes of Section 960.167, F.5.

Complete Application Package: It is your responsibilty to provide a complete application package which includes acceptable documentation proving (2: =
em ocoumsd, I the department receives a report which Is insufficient fo 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 Atiomey's Office

BVC 100 (TH 5) The Office of the Attorney General, Bureau of Victim Compensation is an equal opportunity provider and employer Pagelofd

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PLEASE READ CAREFULLY AND SIGN THE FOLLOWING CERTIFICATIONS
Section 9.

CONFIDENTIALITY: If you are the victim of a sexual battery, aggravated child abuse. aggravated stalking, harassment, aggravated battery, or domastic
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 pericd of five years. If you are the victim of any of these crimes, please mark one of the following statements. Your
response will not the processing of your claim.

| want the information to be confidential [] 1 do NOT want the information to be confidential

SERIOUS FINANCIAL HARDSHIP: | certify that | have a serious financial hardship because of crime-related expenses that cannot be paid by any other
source,

PROPERTY LOSS CERTIFICATION: | certify that the property in question belonged to the victim; that this loss adversely affects the victim's quality of life;
that there is no other source of reimbursement for this loss: and that replacement of the propaty would cause the claimant a serious financial hardship.

RELEASE OF INFORMATION: | give permission to any hospital, doctor, dentist, mental health counselor, or other treatment provider, banking institution,
social sarvice agency, law enforcement agency, comections agency, state atiomey’s office, insurance carrier, attorney or employer to give out information that
is requested conceming any treatment rendered, employment, insurance, third-party payer, of law enforcoment investigative information to the Department
of Legal Affairs for use in processing my claim. | give permission lo the Department to release information about the status of my daim to any treatment
provider, law enforcement agency, of state attomey’s office.

SOCIAL SECURITY NUMBER DISCLOSURE: The Bureau of Victim Compensation collects and uses Social Security numbers for the purpose of performing
imperative duties and responsibilities which may include the following: searching criminal history records, identity management, billing and payments, banefit
processing, and reporiing to authorized state and federal govemment agencies. Failure to provide this optional information may delay the processing of your
application or benefits. Federal and State laws require the Bureau lo protect Social Security numbers from disclosure to unauthorized parties. Absent a waiver
from you or your legal representative, Social Security numbers will be redacted, unless the agancy receives a court onder to urn over a non redacted file.

REPAYMENT REQUIREMENT: | understand that payment by the victim compensation program is a payment of last resort and that | must repay the Crimes
Compensation Trust Fund if | receive a victim compensation award and also recaive 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.
| further understand that | must repay any emergency award from the Crimes Compensation Trust Fund, if ry claim is determined inedigible. | also understand

that if my eligibility is withdrawn, | must repay any amount recaived from the Crimes Compensation Trust Fund.

VICTIM: Must be signed and dated by the victim if filing as a competent adult

Printed Nama:

a 0115/19

and correct to the best of my knowledge.

Signature:

APPLICANT: Applicant signature is required if filing as the parent, legal guardian, or individual authorized to administer a victim's estate.

Printed Name:

Signature: Date:
Under penalty of perjury or fraud, the information | have provided is rue and correct to the best of my knowledge.

NOTARIZATION REQUIREMENT: Persons submitting an application on behalf of an incompetent adult must submit proof of legal guardianship
and have their signature witnessed by a Notary Fublic.

Swom 10 and subscribed before me this day of , 20
[[] personaly known to me. [] identification produced.
Notary Public Signature: Stamp/Seal:
BVC 100 (THE) The Office of the Attarney General, Bureau of Victim Compensation is an equal opportunity provider and employer Page dof 4

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