Referral Form 1Crime Information2Contact Information3Miscellaneous Information Victim's Name* First Last Victim's Age* Victim's Sex*Select One ...MaleFemaleDate of Birth of Victim* MM slash DD slash YYYY Location of Crime* Select Yes If Crime was Committed in KCKS*NoYesDate of Crime* MM slash DD slash YYYY Was the Victim Committing a Crime that Caused Their Death ?*Select One ...YesNoDoes the Victim have Insurance*Select One..YesNoHas the crime been ruled a homicide?* Yes No Not Sure Are you or a family member in contact with law enforcement about the status of the homicide?* Yes No Not Sure Are there any suspects or has an arrest been made for the homicide?* Yes No Not Sure Name* First Last Your full nameEmail* An email at which we may contact youStreet Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you reside in Jackson County Mo. ?* Yes No Phone*Preferred Method of Contact*EmailPhone CallText Message/SMSHow would you prefer to be contacted by us?Relationship to Victim*Please Select...ParentSiblingSpouse/Significant OtherFriendOther (please specify)How do you know the victim?Details* Please describe how you know the victim Add a Secondary Contact Name* First Last Your full nameEmail* An email at which we may contact youPhone*A phone number at which we may contact youStreet Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Preferred Method of Contact*EmailPhone CallText Message/SMSHow would you prefer to be contacted by us?Relationship to Victim*Please Select...ParentSiblingSpouse/Significant OtherFriendOther (please specify)How do you know the victim?Details* Please describe how you know the victim Do you need assistance with the Funeral Service?* Yes No What funeral home is providing the service ?* Which of these services for burial assistance are you aware of?* Crime Victims Compensation KC Common Good Fund I am unaware of both Does the victim have children or siblings under the age of 17* Yes No Please give the age and sex of the children*How many people live in the household ?*As a result of the homicide do you or any family member need free grief counseling?* Grief Counseling for Adult(s) Grief Counseling for Children None Required at this time As a result of the homicide have you been unable to pay or need assistance with any of the following:* Rent or house payment Utilities Food No assistance is required As a result of the homicide are you in fear of retaliation and need relocation?* Yes No Not Sure Your Date of Birth - Req'd for Add'l Services* MM slash DD slash YYYY Annual Household Income - Req'd for Add'l Services* $0 to $10,000 $10,001 to $20,000 $20,001 to $30,000 $30,001 to $40,000 $40,001 to $50,000 $50,001 to $60,000 $60,001 to $70,000 Over $70,000 Refused to Answer Is there anything else you want us to know ?* Yes No Additional Comments*How did you hear about us?* Ad Hoc or Combat Strivin' Hub Friend or Relative Funeral Home KC Mothers in Charge Partners For Peace Police/Police Advocate Social Media TV or Radio News Broadcast or Reporter Corey's Network is affiliated with agencies that assist with funeral cost, case management, and advocacy. Do we have your permission to share information with them?* Yes No CommentsThis field is for validation purposes and should be left unchanged.
