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 EFTA00006055

Have You Been ,. A Victim Of A Crime? Do' Thu Experience Any Of The Following? * Inability to fall orstay asleep? * Feeling anxious or depressed? * Having outbursts of anger? * Inability to concentrate? * reeling 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) 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. 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 coll. 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 O 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 • .0 Play Therapy .0 Assistance for parents during this difficult time Signs Of lPauma 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. 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 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 EFTA00006057

Sexual Assault Domestic Assault Services Provided Professional butting and community presentations are also available. O. Information about Victims' rights 4. 24-hour crisis response to hospitals, law enforcement agencies and crime scenes 0 Sexual Assault Nurse Examiner (SANE) and a Forensic Exam site ti The Butterfly House 4 Sexual Assault Response Team (SART) to provide Victim-centered assistance -4 Criminal Justice advocacy and court accompaniment 4 Assistance with filing State Crime Victim Compensation applications and Restraining Orders O Individual therapy and support groups 0 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: 4 Crisis Intervention and Personal Advocacy Accompaniment during forensic rape exams at The Butterfly House and other medical facilities 0 Coordination of follow-up medical care, therapy and referrals 4 Criminal Justice advocacy and court accompaniment Start by MS, Believing Start by Believing: A Public Awareness 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. 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 4 Safety Planning 0 Assistance with filing Restraining Orders 0 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 0 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 EFTA00006058

Help is Available 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. Forensic Exam 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. EFTA00006059

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 EFTA00006060

Center for Trauma Counseling Where Your Emotional Healing Can Begin 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.parrnbeachmentalhealth.org EFTA00006061

Office of the Attorney General The Capitol. PL-01 • Tallahassee, FL 3230-1050 . Office: (800)2264687 Fax: (853) 414.6191 Bill Status Inform:tier for Providers 050) 414-3331 • TDD users may call through Florida Relay Service at 1.803.9558771 'Nebsite: myfloridalegalcom • Email address: [email protected] 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. I' you move or change your address. you are required to notify this office. CHECK THE TYPE Of VICTIM COMPENSATION BENEFITS YOU ARE REQUESTING: Fl DISABILITY - compensation for the victim who suffered a Donnell cisatilty. I—I (Attach documentasn as cktined in Section 3.) Eg WAGE LOSS - compensation fa the victm who lost wages due to crime related ph injuries (Math 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 Cournentaticn as alined in Section 4.) EXPENSES • payment cc retnticrsenent on oehSt of the victim for cnme-retaed funeral/burial, medical/dente treatment and mental health cornseing expenses: as well as aesoiptions, eyeglasses, dentures, ons prosthetic &Ake lost damaged, or required because of cone. (Attach termed bels and receip treatment/funeral O FUNERAL/BURIAL EDICALMENTAL NTAL HEALTWGRIEF TREATMENT COUNSELING in EMERGENCY ASSISTANCE - relmtursement fu dixturnented wage bee and out-of-packet a/pauses related b da Came. (Attach receipts.) CHECK ALL OTHER TYPES OF 8 ENEFFS YOU ARE REOUESTNG: (Separate claim numbes we be assigned.) In PROPERTY LOSS for an Wuh over the age of 60 or enabled adult ,attach proof disabity pre( to the dab) of nine from a physician a the Social Security Administraton) who suflered the loss of tamable serSOna: property, as the restlt of a criminal or delinquent act. Math a receipt of written estinate train a vendor or merchant identifying lie comparable replacement value. Compensabie items mist be identified by the law enforcement report In SEXUAL BATTERY RELOCATION ASSISTANCE - for the vctm of sexual Celery seeking assstance b relocate due to reasonable fear A certified rape crisis center certificatior form must be received with Ine appintion. Section 1. Victim and Applicant Information VICTIM'S NAME (lar. Net mcldle) SOCIAL SECURITY NO. ADORE TELEPHONE NUMBER ALTERNATE PHONE NUMBER TITS INFORMATION IS COLLECTED FOR FEDERAL REPORTING PURPOSES AND IS OPTIONAL. RAMETHINICEY CIMAERICAN 'MAW EIASLAN BLACIVATRICAN rl HISPANIC cr I--IkLASKA NATIVE I—I AMERICAN L.—I LATINC (- 1 DOMESTIC VIOLENCE RELOCATION ASSISTANCE - be the victim of donestc violence seeking assistance to relocate to a sate environment. A cerifieo domesic violence certif talon form and applcaton nust be receved with 33 days horn the date of crime. ri HUMAN TRAFFICKING RELOCATION ASSISTANCE - for the vctiir of sexual traffickng with an urgent need to relocate. A rape orals or domestic ‘iolence certer cerbicaton fern and applicator] must be received within 45 days of the last identifiable threat. CCCUPATICe gala wv-ety.r.va,A- O NATIVE HAWAIIAN or OTTER PACIFIC ISLANDER K OTHER RACE O eiLLTIRE RACES WHITE NONLKINOCAUCASIAN GENDER: ti !it The 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 of legal guardianship must be attached, and the applicant's signature an tie dairr form must oe witnessed by a Notary Public. IS THE VICTIM icheo ore) DECEASED O INJURED MINOR K Al" INJ WITNESS" O INCOMPETENT NOT URED APPLICANT NNE Bed. first middle) DATE OF BIRTH / / SOCIAL ' E-MAIL SECURITY NO. I ADDRESS WOULD YOU UKE ALL CORRESPONDENCE SENT BY EMAIL? YES NO ADDRESS CITY STATE ZIP CODE TEL EPHosE / TAMER k ALTERNATE i PHONE NUMSER k RELATIONSHIP TO vICTIM OCCUPATION NATIONAL ORIGIN likS P1 WAS VICTIM DISABLED BEFORE THE CRIME OCCURRED? D YES EIVC lee Vt15) The Mee of the Attorney General. Bureau of Victim Compensation is an equal opportunity provider and empasyer. Page 1 of it EFTA00006062

Section 2. Referral Source Information Individuals 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 affirms that all information provided is true and correct, and thus. al sections should be reviewed before the application is signed. (Treatment providers can request training on the Victim Compensation Program. which is recommended prior to becoming a referral source.) MME OF PERSON ASSISTING WITH APPLICATION I EMAIL past first mimic) ADDRESS hAME OF AGENCY/ORGANIZATION AGENCY ORGANZATIONS ADDRESS (address. city, state, zip code) Section 3. Disability or Lost Wages Information Men 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* or 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 wtich 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 AssoParn Gtitlekes ar Sktifia Imparrre7t Patric Gudekes. and favrad &oat SepolykInwasaatcr award leders ELEPHQNE NUMBER SUPERVISOR'S WE liAl.E OF COMPANY/BUSINESS le we ban ere In ernotiyar,pkeie mach looms 'heel CONPAINY ADDRESS Iaddress. city state, zip code) IS WAGE LOSS COVERED BY INSURANCE? LI YES IS WAGE LOSS COVERED BY WORKER'S COMPENSATION? I-1"° YES TELENCINIE WEER ) NIJ IS VICTIM DISABLED AS A RESULT OF THE CRIME? n YES I I NO n NO Section 4. Loss of Support Information or Grief Counseling Information '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 3t•eSI income tar rein and individual earnings statement reemploynont assistance benefit statement. tour rimer for support. birth mrtficate which idenbfies dependent viationship, marriage cerhficato, or legal documentation proving principal suapidt. DEPENDANTAUNCR CLAINAN- NAME(S) DATE OF BIRTH RELATIONSHIP TO MTN Section 5. Insurance Information Clements who are determined eligible for the Vctim Compensation and Prcoerty Loss Program may be 'mem( Iran the irsurance deductble or co-payment provisions Of their insurance policyQes). IS INSURA.NCE OR MEDCAJD AVAILABLE TO ASSIST WITH THESE EXPENSES? O YES NO MEDICAID NUMBER yes, prende be foaming ix d inwrance paces. including lAerliceid Medicare. Flo hanoonnoq. ailomobit, or moice medal &tad as related insdarce Expknabcn Of Senses statardends). i COMPANY NAME AV-C (AM ilVt WAWA NUMBE 0 - 40 - 115 - 258- 5 ADDRESS CITY ZIP CODE 2. COMPANY NAME POLICY NUMBER TELEPHONE/ NUMBER ADDRESS CITY STATE Zr CODE I TELEPHRONE/ Section 6. Other Compensation, Settlement, and Attorney Information You 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 notify this office if you have or are laming to hire an attorney to represert you as a result of the incident STATE THE SOURCE AND DATE RECEIVED (IFAPFUCAN1) 0 I ‘S-I t 41 I ARE YOU REPRESEN-ED_ / I BY LEGAL COUNSEL? L' S 0 NO ATTORNEY'S NAME I ADDRESS EMAIL ADDRESS I TELEPHONE NUMBER CITY STATE ZIP CODE \ BY; 100 tits) The Office of the Attorney General, Bureau of Victim Compensation is an equal oeportoney provider and employe, Pogo 2 of 4 EFTA00006063

Section 7. Crime Information This 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 your application not being processed or your claim being denied. NAME OF LAW DATE OF CRIME I DATE REPORTED TO LAW ENFORCEMENT AGENCY ENFORCEMENT AGENCY WAS THE CRP& j REPORTED TO LAW ENFORCEMENT WITHIN 72 HOURS? YES ONO If no. please explain. (II no. failure to provide an acceptable explanation in this section will result in a denial of beneib.) IS THE APPLICATION AND LAW ENFORCEMENT REPORT BEING SUBMITTED WITHIN ONE YEAR FROM THE DATE OF CRIME? K YES 13 NO If 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 II no. Mime to Monde an %Made explanation in this seams MI result n a denial of bonen.) TYPE OF CRIME AS SPECIFIED ON THE LAW ENFORCEMENT REPORT NAME OF LAW ENFORCEMENT OFFICER NME OF ASSISTANT STATE ATTORNEY HANDLING THE CASE Of applicatle) LAW ENFORCEMENT REPORT NUMBER Section 8. Eligibility Requirements NAME OF OFFENDER Nlmoitin) STATE ATTORNEY! CLEW OF COURT CASE NUMBER (if appicable) Additional qualification criteria. deadlines, and exceptions not listed may apply. Victim Compensation (VC): The victim must cooperate fuly with law enforcement officials, State Attorneys Office, and the Attorney General's Office. The clime 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 fling 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 $1,000 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 a 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 ipty 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 child protection team, law enforcement agency, state or prosecuting attorney. or the Department 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 cybercrime 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 come 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 Attomey's Office. BVC 100 (7/15) The Office of the Attorney General, Bureau of Victim Compensation is an equal opportunity provider and employer. Page 3 of 4 EFTA00006064

PLEASE READ CAREFULLY AND SIGN THE FOLLOWING CERTIFICATIONS Section 9. CONFIDENTIALITY: If you are Ire victim of a sexual battery. aggravated chid abuse. aggravated stalking, harassment, aggravated battery, or domestic violence. you have the rignt to have information about your home address and telephore 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 affe the processing of your claim. I want the information to be confidential O I do NOT want the information to be confidential SERIOUS FINANCIAL HARDSHIP: I certify that I have a senous financial hardship because of crime-related expenses that cannot be paid by any other source. PROPERTY LOSS CERTIFICATION: I eerily 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 prope-ty would cause the claimant a serious financial hardship. RELEASE OF INFORMATION: I give permission to any hospital, doctor. dentist, mental health counselor, or other treatment provider, bankng triStrtution, social service agency, law enforcement agency. corrections agency, state attorney's office, inssance carrier, attorney or employer to give out information that is requested concerning any treatment rendered, employment Insurance thrd-party payer, or law enforcement nvestigative information to the Department of 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 provider, law enforcement agency. or state attorney's office. SOCIAL SECURITY NUMBER DISCLOSURE: The Bureau cf Victim Compensation collects and uses Social Security numbers for the purpose of performing mperatve duties and responsiNifieswtoch may include the forowing: searching criminal history records. identity management. biting and payments, benefit processing. and reporting to authorized state and federal government agencies. Failure to provide this optimal information may delay lhe processing of your application or benefits. Federal and State laws fracture the Bureau to protect Social Security numbers from disclosure to ulauthoized 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 also receive payment from another source as a result of the same crrninal incident Otter 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 understard that I must repay any emergency award from the Cnmes Compensation Trust Fund, If my claim is determined ineligible. I also understand that if my eligibility is withdrawn, I must repay any amount received from the Crimes Compensation Trust Fund. APPLICANT: Applcant signature is required if Mine as the parent. legal guardian. a individual authorized to administer a vctirts estate. Pnnted Name: Signature: Date. Under Penalty of Perjury or fraud, the information I have provided is true and correct to the best o' my knowledge. NOTARIZATION REQUIREMENT: Persons submitting an application on behalf of an incompetent adult must sibmit prin.,' or legal guarcianship and have their signalize mtnessed by a Notary Public. Sworn to and subscribed oefore nit this day of . 20 Personalty known to me. Identification produced. Votary Pottle Signature: Stamp/Seal: BVC 10i (-7/15) The Office or the Attorney General, Bureau of Victim Compensation is en equal opportunity provider rid employer Page 4 of 4 EFTA00006065