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P.O. BOX 421 FORT LAUDERDALE FLORIDA 33302
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Home
About BVRC
Our Board
Membership
Membership
RLK Assistance Application Form
Membership Payment System
Garden of Reflection
Contact Us
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
What other resources has the victim applied for?
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
Submit
Every Day
Every Hour in America there are
2 Murders
2 Drunk Driving Deaths
28 Rapes
58 Robberies
67 Attacks on Women by Someone They Know
103 Neglectful or Abusive Acts Toward Children
157 Stalkings
Broward victim’s rights coalition
P.O. BOX 421 FORT LAUDERDALE FLORIDA 33302
Telephone: 954.357.5775 Ext. 5761 Fax: 954.602.3532
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