Survivor or Victim Application

Primary Victim Information

Questions with a red asterisk (*) are required fields
Name * Required
First Middle Last
Birth Date * Required
MM slash DD slash YYYY
Address * Required
Street Address Address Line 2 City State ZIP Code
Phone * Required
Email * Required
Gender * Required

Please input how you identify
Race(s) * Required

Please input how you identify
Crime Information

Please request assistance from your Victim Advocate before Completing this section
Date of Crime * Required
MM slash DD slash YYYY
Law Enforcement Agency * Required
0 of 75 max characters
Law Enforcement Case Number * Required
0 of 50 max characters
County where Crime Occurred * Required
Is this case part of the NC Rape Kit Backlog?
If yes, when was the victim/survivor notified of the status of their kit?
MM slash DD slash YYYY
Advocate's Information
Advocate's Name
First Last
Advocate's Agency
0 of 50 max characters
Advocate's Phone Number
Advocate's Email
Emergency Fund Need
Please describe the survivor's financial needs as related to the recent notification from their cold case sexual assault * Required
0 of 500 max characters
Financial Assistance Request * Required
Name of Company Address of Company Estimated Amount
Estimated Total
Authorization
Please Read Carefully
I hereby authorize the release of any information deemed necessary by the North Carolina Department of Justice for a determination of the eligibility of this claim for benefits including information or documents that are classified as private or controlled under the North Carolina Public Records Act. Such information will be used to evaluate the eligibility of your application and your eligibility for the Sexual Assault Kit Initiative Survivor Fund may be provided to law enforcement agencies, prosecuting agencies, and other providers.

APPLICATIONS SUBMITTED FOR CHILD VICTIMS UNDER THE AGE OF EIGHTEEN MUST BE COMPLETED AND SIGNED BY THE CHILD’S PARENT OR LEGAL GUARDIAN.
Victim or Applicant Signature * Required
Date * Required
MM slash DD slash YYYY
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Contact

For questions related to the Survivor Fund Applications and for survivor support, please contact Cynthia Clark, SAKI Victim Advocate, at survivorfund@ncdoj.gov or (919) 716-6517.

For questions about invoices and billing, please contact Juliette Grimmett at jgrimmett@ncdoj.gov or (919) 624-9575. Please note, all invoices should be emailed to Juliette Grimmett

Name of Company	Address of Company	Estimated Amount

Survivor or Victim Application

Primary Victim Information

Crime Information

Advocate's Information

Emergency Fund Need

Authorization

Contact