RLK Assistance Application Form

Rebecca Lee Knox Crime Victim Assistance Fund Application Form

Your Name *

Email *

Contact number for the member applying on behalf of the victim

Amount of request

Provide a detailed description of the amount and purpose of requested funds.

Describe how the need relates to the crime.

What other resources has the victim applied for?

Provide plan to sustain need after funding is provided.

If the need is greater than the max of $500, please explain how the victim will make up the difference.

Victim's Information

Victim Name

Type of Crime

Date Crime Occurred

Provider Agency

Request within 60 days

Yes No

If no, please explain

Name and Address of Payees

First Name *

Last Name *

Address

Street Address

City

State

ZIP / Postal Code

Detailed Discription

Vendor Name

Vendor Invoice No

Applicant Account No

Provider Signature Date

Victim Signature Date

P.O. BOX 421 FORT LAUDERDALE FLORIDA 33302
Telephone: 954.357.5775 Ext. 5761 Fax: 954.602.3532