Rebeca Lee Knox Crime Victim Assistance Fund Application Form

Victim Name

Type of Crime

Date Crime Occurred

Provider Agency Pr Referral source Note: Must be a BVRC member in good standing

Request within 60 days

YES No

If not please explain

Please provide a detailed description of the amount and purpose of requested funds. List attempts to secure funding from other sources and outcome(s). Please attach additional sheets if needed.

Please provide the name and address of payee(s)

If payee is different than applicant, complete the following:

Vendor Name

Vendor Invoice No

Applicant Account No

By submitting this form you are verifying that the information provided is valid to the best of your knowledge. In addition, you consent to the release of this information to the above named payee(s) on your behalf by the BVRC Rebecca Lee Knox Crime Victim Assistance Fund. Please note that receipts may be required for all expenditures.

Provider Signature Date

Victim Signature Date