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.

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 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.

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

Like Us on



PBCVictim Services

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

May 2019

BEACH COUNTY Palm Beach County
Public Safety Department
FLORIDA Victim Services Division

Victim Services

& Certified

Rape Crisis Center

Therapy Services

Serving Victims of Violent Crimes

EFTA00006055



## Have You Been
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)



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.

## Services 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:

	- 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

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

	- Experience a reduction of trauma symptoms

	- Return to work or school

	- Explore the impact on current and future
relationships

## Therapy For
Children & Teenagers

	- Assessment and treatment for child victims
of crime

	- Therapeutic interventions that teach
child safety

◆ 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.

	- 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.

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

	- 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.

## Mission Statement (cont.)

Florida Statute 960 Provides
Guidelines For Fair Treatment
& Specific Rights For Victims
In The Criminal Justice System
Some of these include the following:

- 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;

- 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 and/or 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.

## Mission Statement (cont.)

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

## Mission Statement (cont.)

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.

Like Us on

LORID f
Palm Beach County
Board of County Commissioners PBCVictimServices
Rev. May 2019

BEACH COUNT Palm Beach County
Public Safety Department
FLORIDA Victim Services Division

# Victim Services
& Certified
Rape Crisis Center
Serving Victims of Violent Crimes



EFTA00006057

# Victim Services
& Certified
Rape Crisis Center
Serving Victims of Violent Crimes (cont.)

## 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

	- 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



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.

# Victim Services
& Certified
Rape Crisis Center
Serving Victims of Violent Crimes (cont.)

## 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.

# Victim Services
& Certified
Rape Crisis Center
Serving Victims of Violent Crimes (cont.)

## 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

→ Coordination of follow-up medical care, therapy
and referrals

- Criminal Justice advocacy and court accompaniment

Start by
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

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 filing Restraining Orders

- Safe-Shelter Referrals

- Personal and legal advocacy during
criminal justice proceedings

# Victim Services
& Certified
Rape Crisis Center
Serving Victims of Violent Crimes (cont.)

## 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

EFTA00006058

# Help is Available

# Sexual Battery is a Crime!

# Sexual Battery is a Crime! (cont.)

## Forensic Exam



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! (cont.)

## Forensic Exam (cont.)



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

# Sexual Battery is a Crime! (cont.)

## 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

# Victim Bill of Rights

## Victim Compensation

## Resources

# Victim Bill of Rights (cont.)

## 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



## 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

# Victim Bill of Rights (cont.)

## 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.

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@fdle.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

# Victim Bill of Rights (cont.)

## 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

March 2017 -4000

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: info@palmbeachmentalhealth.org

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

EFTA00006061

ATTORNEY COENER

# Office of the Attorney General

The Capitol, PL-01 Tallahassee, FL 32399-1050 Office: (800) 226-6667 Fax: (850) 414-6197 Bill Status Information for Providers (850) 414-3331 TDD users may call through Florida Relay Service at 1-800-955-8771 Website: myfloridalegal.com Email address: vcintake@myfloridalegal.com

BV

# 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 address, you are required to notify this office.

CHECK THE TYPE OF VICTIM COMPENSATION BENEFITS YOU ARE REQUESTING:



DISABILITY-compensation for the victim who suffered a permanent disability. (Attach documentation as outlined in Section 3.)



✓ WAGE LOSS - compensation for the victim who lost wages due to crime related

physical injuries. (Attach documentation as outlined in Section 3.)



LOSS OF SUPPORT - compensation for the dependent(s) of a deceased victim who was employed at the time of the crime. (Attach documentation as outlined in Section 4.)

# BUREAU OF VICTIM COMPENSATION CLAIM FORM (cont.)

## Instructions (cont.)

EXPENSES-payment or reimbursement on behalf of the victim for crime-related funeral/burial, medical/dental treatment, and mental health counseling expenses; as well as prescriptions, eyeglasses, dentures, or a prosthetic device lost, damaged, or required because of the crime. (Attach itemized bills and receipts from treatment funeral providers.) FUNERAL/BURIAL MEDICAL/DENTAL MENTAL HEALTH/GRIEF TREATMENT COUNSELING EMERGENCY ASSISTANCE - reimbursement for documented wage loss and out-of-pocket expenses related to the crime. (Attach receipts.)

# BUREAU OF VICTIM COMPENSATION CLAIM FORM (cont.)

## CHECK ALL OTHER TYPES OF BENEFITS YOU ARE REQUESTING: (Separate claim numbers will be assigned.)

PROPERTY LOSS - for an adult over the age of 60 or disabled adult (attach proof of disability prior to the date of crime from a physician or the Social Security Administration) who suffered the loss of tangible personal property as the result of a criminal or delinquent act. Attach a receipt or written estimate from a vendor or merchant identifying the comparable replacement value. Compensable items must be identified by the law enforcement report.

SEXUAL BATTERY RELOCATION ASSISTANCE - for the victim of sexual battery seeking assistance to relocate due to reasonable fear. A certified rape crisis center certification form must be received with the application.

# BUREAU OF VICTIM COMPENSATION CLAIM FORM (cont.)

## CHECK ALL OTHER TYPES OF BENEFITS YOU ARE REQUESTING: (Separate claim numbers will be assigned.) (cont.)

DOMESTIC VIOLENCE RELOCATION ASSISTANCE - for the victim of domestic violence seeking assistance to relocate to a safe environment. A certified domestic violence certification form and application must be received within 30 days from the date of crime.

HUMAN TRAFFICKING RELOCATION ASSISTANCE - for the victim of sexual trafficking with an urgent need to relocate. A rape crisis or domestic violence center certification form and application must be received within 45 days of the last identifiable threat.

# BUREAU OF VICTIM COMPENSATION CLAIM FORM (cont.)

## Section 1. Victim and Applicant Information

VICTIM'S NAME (last, first, middle): <empty>
DATE OF BIRTH: <empty>
SOCIAL SECURITY NO.: <empty>
E-MAIL ADDRESS: <empty>
WOULD YOU LIKE ALL CORRESPONDENCE SENT BY EMAIL?:
[x] YES
[ ] NO
ADDRESS: <empty>
CITY: North Palm Beach
STATE: FL
ZIP CODE: 33408
TELEPHONE NUMBER: <empty>
ALTERNATE PHONE NUMBER: <empty>
OCCUPATION: Retail Management
THIS INFORMATION IS COLLECTED FOR FEDERAL REPORTING PURPOSES AND IS OPTIONAL.
RACE/ETHNICITY:
[ ] AMERICAN INDIAN/
[ ] ASIAN
[ ] BLACK/AFRICAN AMERICAN
[ ] HISPANIC or LATINO
[ ] NATIVE HAWAIIAN or OTHER PACIFIC ISLANDER
[ ] OTHER RACE
[ ] MULTIPLE RACES
GENDER:
[ ] Male
[x] Female
NATIONAL ORIGIN: USA
WAS VICTIM DISABLED BEFORE THE CRIME OCCURRED?:
[ ] YES
[x] NO
The applicant filing on behalf of a victim is required to provide claimant information below. When requesting compensation on behalf of an incompetent adult victim, proof of legal guardianship must be attached, and the applicant's signature on the claim form must be witnessed by a Notary Public.
IS THE VICTIM (check one):
[ ] DECEASED
[ ] INJURED MINOR
[ ] MINOR WITNESS - NOT INJURED
[ ] INCOMPETENT
APPLICANT NAME (last, first, middle): <empty>
DATE OF BIRTH: <empty>
SOCIAL SECURITY NO.: <empty>
E-MAIL ADDRESS: <empty>
WOULD YOU LIKE ALL CORRESPONDENCE SENT BY EMAIL?:
[ ] YES
[ ] NO
ADDRESS: <empty>
CITY: <empty>
STATE: <empty>
ZIP CODE: <empty>
TELEPHONE NUMBER: <empty>
ALTERNATE PHONE NUMBER: <empty>
RELATIONSHIP TO VICTIM: <empty>
OCCUPATION: <empty>

# BUREAU OF VICTIM COMPENSATION CLAIM FORM (cont.)

## Section 1. Victim and Applicant Information (cont.)

BVC 100 (7/15)

The Office of the Attorney General, Bureau of Victim Compensation is an equal opportunity provider and employer.

Page 1 of 4

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 application, the victim/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 recommended prior to becoming a referral source.)

NAME OF PERSON ASSISTING WITH APPLICATION (last, first, middle):<empty>
E-MAIL ADDRESS:<empty>

NAME OF AGENCY/ORGANIZATION:<empty>

AGENCY/ORGANIZATION'S ADDRESS (address, city, state, zip code):<empty>
TELEPHONE NUMBER:<empty>

# BUREAU OF VICTIM COMPENSATION CLAIM FORM (cont.)

## Section 3. Disability or Lost Wages Information

When requesting compensation for lost wages, attach a copy of your pay stub or eamings statement which identifies your employment status and wages at the time of the crime. If you are self-employed or work for a family member, attach a copy of your latest income tax retum and applicable IRS schedule forms. If more than 5 work days were missed as a result of the crime, attach a doctor's letter which excused you for this absence. When requesting disability compensation, attach a doctor's letter which specifies each crime related permanent disability rating according to the American Medical Association Guidelines or Florida Impairment Rating Guidelines, and forward Social Security Administration award letters.

SUPERVISOR'S NAME:<empty>
TELEPHONE NUMBER: ( <empty> )

NAME OF COMPANY/BUSINESS (if more than one [1] employer, please attach additional sheet):<empty>

COMPANY ADDRESS (address, city, state, zip code):<empty>

IS WAGE LOSS COVERED BY INSURANCE?:
[ ] YES
[ ] NO

IS VICTIM DISABLED AS A RESULT OF THE CRIME?:
[ ] YES
[ ] NO

IS WAGE LOSS COVERED BY WORKER'S COMPENSATION?:
[ ] YES
[ ] NO

# BUREAU OF VICTIM COMPENSATION CLAIM FORM (cont.)

## Section 4. Loss of Support Information or Grief Counseling Information

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

DEPENDANT/MINOR CLAIMANT NAME(S)

DATE OF BIRTH

RELATIONSHIP TO VICTIM

# BUREAU OF VICTIM COMPENSATION CLAIM FORM (cont.)

## Section 5. Insurance Information

Claimants who are determined eligible for the Victim Compensation and Property Loss Programs may be exempt from the insurance deductible or co-payment provisions of their insurance policy(ies).

IS INSURANCE OR MEDICAID AVAILABLE TO ASSIST WITH THESE EXPENSES?  YES  NO MEDICAID NUMBER:

If yes, provide the following for all insurance policies, including Medicaid, Medicare, life, homeowner's, automobile, or major medical. Attach all related insurance Explanation of Benefits statement(s).

1. COMPANY NAME
Blue Cross Blue Shield
ADDRESS

POLICY NUMBER

NUMBER (1-800-275-2583 TELEPHONE

CITY

STATE

ZIP
CODE

2. COMPANY NAME

POLICY NUMBER

NUMBER

TELEPHONE )

ADDRESS

CITY

STATE

ZIP
CODE

# BUREAU OF VICTIM COMPENSATION CLAIM FORM (cont.)

## Section 6. Other Compensation, Settlement, and Attorney Information

You must notify this office if 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 notify this office if you have or are planning to hire an attorney to represent you as a result of the incident.

STATE THE SOURCE AND DATE RECEIVED (IF APPLICABLE): 10/15/19
ARE YOU REPRESENTED BY LEGAL COUNSEL?:
[x] YES
[ ] NO
ATTORNEY'S NAME: <empty>

ADDRESS: <empty>
E-MAIL ADDRESS: <empty>

CITY: <empty>
STATE: <empty>
ZIP CODE: <empty>
TELEPHONE NUMBER: <empty>

BVC 100 (7/15)

The Office of the Attorney General, Bureau of Victim Compensation is an equal opportunity provider and employer.

Page 2 of 4

EFTA00006063

## 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 will result in your application not being processed or your claim being denied.

NAME OF LAW
ENFORCEMENT AGENCY

# BUREAU OF VICTIM COMPENSATION CLAIM FORM (cont.)

## Section 7. Crime Information (cont.)

DATE OF
CRIME

DATE REPORTED TO LAW
ENFORCEMENT AGENCY

WAS THE CRIME REPORTED TO LAW ENFORCEMENT WITHIN 72 HOURS? YES NO If no, please explain. (If no, failure to provide an acceptable explanation in this section will result in a denial of benefits.)

IS THE APPLICATION AND LAW ENFORCEMENT REPORT BEING SUBMITTED WITHIN ONE YEAR FROM THE DATE OF CRIME? YES NO 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 exceptions 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 ON THE LAW ENFORCEMENT REPORT:<empty>
LAW ENFORCEMENT REPORT NUMBER:<empty>

NAME OF LAW ENFORCEMENT OFFICER:<empty>
NAME OF OFFENDER (if known):<empty>

NAME OF ASSISTANT STATE ATTORNEY HANDLING THE CASE (if applicable):<empty>
STATE ATTORNEY/ CLERK OF COURT CASE NUMBER (if applicable):<empty>

## Section 8. Eligibility Requirements

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

# BUREAU OF VICTIM COMPENSATION CLAIM FORM (cont.)

## Section 8. Eligibility Requirements (cont.)

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 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 $1,000 on all claims.

# BUREAU OF VICTIM COMPENSATION CLAIM FORM (cont.)

## Section 8. Eligibility Requirements (cont.)

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.

# BUREAU OF VICTIM COMPENSATION CLAIM FORM (cont.)

## Section 8. Eligibility Requirements (cont.)

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.

# BUREAU OF VICTIM COMPENSATION CLAIM FORM (cont.)

## Section 8. Eligibility Requirements (cont.)

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.

# BUREAU OF VICTIM COMPENSATION CLAIM FORM (cont.)

## Section 8. Eligibility Requirements (cont.)

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.

# BUREAU OF VICTIM COMPENSATION CLAIM FORM (cont.)

## Section 8. Eligibility Requirements (cont.)

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 (7/15) The Office of the Attorney General, Bureau of Victim Compensation is an equal opportunity provider and employer.

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# PLEASE READ CAREFULLY AND SIGN THE FOLLOWING CERTIFICATIONS

# PLEASE READ CAREFULLY AND SIGN THE FOLLOWING CERTIFICATIONS (cont.)

## Section 9.

CONFIDENTIALITY: If you are the victim of a sexual battery, aggravated child abuse, aggravated stalking, harassment, aggravated battery, 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 affect the processing of your claim.



I want the information to be confidential

I do NOT want the information to be confidential

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

PROPERTY LOSS CERTIFICATION: I 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 property would cause the claimant a serious financial hardship.

# PLEASE READ CAREFULLY AND SIGN THE FOLLOWING CERTIFICATIONS (cont.)

## Section 9. (cont.)

RELEASE OF INFORMATION: I give permission to any hospital, doctor, dentist, mental health counselor, or other treatment provider, banking institution, social service agency, law enforcement agency, corrections agency, state attorney's office, insurance carrier, 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 agency, or state attorney's office.

# PLEASE READ CAREFULLY AND SIGN THE FOLLOWING CERTIFICATIONS (cont.)

## Section 9. (cont.)

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, benefit processing, and reporting to authorized state and federal government agencies. Failure to provide this optional information may delay the processing of your application or benefits. Federal and State laws require the Bureau to 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 agency receives a court order to turn over a non redacted file.

# PLEASE READ CAREFULLY AND SIGN THE FOLLOWING CERTIFICATIONS (cont.)

## Section 9. (cont.)

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 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 Crimes 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.

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

Printed Name:

Signature: Date: 10/15/19

rue and correct to the best of my knowledge.

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

Printed Name:

Signature:

# PLEASE READ CAREFULLY AND SIGN THE FOLLOWING CERTIFICATIONS (cont.)

## Section 9. (cont.)

Date:

Under penalty of perjury or fraud, the information I have provided is true 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 Public.

Sworn to and subscribed before me this day of
Personally known to me. Identification produced.

20

Notary Public Signature:

Stamp/Seal:

BVC 100 (7/15)

The Office of the Attorney General, Bureau of Victim Compensation is an equal opportunity provider and employer.

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documents/EFTA00006055.pdf
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