In Our Names Network Police Violence Survivors Fund Application
In Our Names Network is a national network of organizations, campaigns and individuals working to end police violence against Black women, girls, trans and gender nonconforming people. One of the ways we are fighting police violence is to directly intervene and mitigate the harms and complexities that are caused by this violence. Therefore, we have established a Survivor’s Fund that will act as a direct aid and mini grant program for individuals targeted by racialized and gendered police violence and criminalization. The Survivor’s Fund directly supports survivors of physical, sexual, economic, and fatal violence by police, as well as people subject to family policing and separation by providing them tangible resources to heal and re-root their lives in safety.
To receive funds from the PV Survivor's fund you must be Black, have experienced police violence, be able to complete a W9 form and provide bank information as payments will be made via ACH or check. Also, Paypal payments will only be acceptable under certain circumstances. If you are able to meet these criteria please type "yes" in the box below.
Legal Name
First Name
Last Name
Preferred Name
First Name
Last Name
Pronouns
Contact Number
Please enter a valid phone number.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you identify as a Black women, girl, trans or queer person?
Yes
No
Are you a survivor of police violence AND need financial support and resources? (hospital bills, moving fees, need to break a lease, court fees, child care etc?)
Yes
No
How would receiving these funds change your life circumstances? What material or other needs will be met by receiving these funds?
Who are your current support systems (Family members, organizations or individuals)? Are you connected to any community based organizations/ activist/ organizers?
Can you explain the level of urgency for your request?
What is your family situation? Are you a caretaker? Do you need support such as childcare, etc?
We will review all applications based on urgency and risk level. Please list how the funds will be utilized (ex. replacement costs, moving expenses, medical care etc) and provide an estimated cost for each item listed.
Submit
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