Fordyce Survivors Fund

Fordyce Survivors Response Fund - Application for Benefits
You are now beginning an official Application for Benefits. You may choose Save at the bottom of any page to finish the application later, but you must finish this application by hitting the “SUBMIT” button on the final page by the application deadline specified in the fund protocol.

If you do not see a screen confirmation message and receive an e-mail message confirming that you have completed the application, you have not formally submitted the application and are not yet eligible for benefits. NOTE: this email may go to your SPAM folder, so please check there if you do not receive an email after submitting your application.

Instructions:
- You may choose Save at any time to finish the application later. When saving your application to return to it later, you do not need to create an account in order to save your application. Instead, simply click “Skip Create an Account” at the bottom of the dialogue box, and enter your email address to be sent a unique link that you can use to return to your application at a later time. NOTE: this email may go to your Spam folder.
- You must finish this application by hitting the “SUBMIT” button on the final page by the application deadline specified in the Fund’s Final Protocol. NOTE: If you do not see a screen confirmation message and receive an e-mail message confirming that you have completed the application, you have not submitted your application.
- Fields marked with an * are required.
- To move between pages of the application, use the “Back” button at the bottom of the page instead of the button in your browser to return to the previous webpage.
Important Terms:
- "Applicant" refers to you – the person completing this Application for Benefits.
- "Victim" refers to the person directly affected by the event. This could be a decedent or a person physically present and/or injured during the event. In some cases, the Victim will also be the Applicant, but in other cases, someone other than the victim may apply on behalf of the Victim.
- "Representative" refers to the authorized or legal representative of the Victim.
- "Beneficiary" refers to the legal or designated heir(s) of deceased Victims.
- "Fund Administrators" refer to the Mass Violence Survivors Fund representatives working with the local Steering Committee to manage the Fund.
The rules for how these funds are to be distributed is governed by the Final Protocol which is available online at:
- Final Protocol
I acknowledge that: 1) the financial benefits paid by the fund are a gift to which no person has a legal claim or entitlement and 2) all aspects of this final protocol including, without limitation, the classifications of applicants, the distribution criteria, the application process, timetable, and amounts to be awarded, may be revised, and are subject to the full and complete discretion of the Administrators.*

I acknowledge
Category A - Application for Legal Heirs of those who were killed as a direct result of the shootingsCategory B - Application for Those who were physically injured by cunshot wound in the shootingCategory C - Application for Those who suffered some other type of physical injury during the shootingCategory D - Application for Those who were present at the time of the shooting and suffered psychological trauma
When completing an Application for Death Benefits, you will be required to upload documentation at various steps in the process. This includes:
- A death certificate
- A copy of the will (if one exists)
- Documentation proving the applicant's relationship to the Victim (for example, a marriage certificate, birth certificate, letter of appointment, or proof of representation, etc.)
- If the decendent did not have a will, you will be required to submit proof of the relationship of each beneficiary to the decedent (for example, a marriage certificate or birth certificate)
- If the decendent was not married at the time of their death, but had been previously married, documentation proving the dissolution of a Victim's marriage prior to their death (for example, a divorce decree or death certificate for the Victim's former spouse)
- Completed, notarized Consent to Distribution forms for each beneficiary. The Consent to Distribution Form can be downloaded via the following links:
  - Consent to Distribution Form (English)
While it is possible to save a partially completed application, we strongly encourage applicants to have the documentation above ready prior to starting the application process.

Applicant's Contact Information
NOTE: The information on this page should be about the Applicant and not the Victim. Information about the Victim will be entered later in the application.
Applicant's Name*

First NameLast Name
Applicant's Email*
Note: Please provide an email address that you check regularly. This email address will be used for all communication related to this Application, and will be the primary mode of communication used to resolve any deficiencies in the Application.
Applicant's Phone Number*

Area Code
Applicant's Alternate Phone Number

Area Code
Applicant's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please upload a government-issued ID to confirm your identity as an applicant. Upload FRONT of Govt. ID*

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Upload the Front of your government ID Cancelof
Please upload a government-issued ID to confirm your identity as an applicant. Upload BACK of Govt. ID*

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Upload the Back of your government ID Cancelof

Payment Information
Funds are distributed once the Steering Committee approves a distribution plan for approved applicants. Funds will be distributed in the following ways:
- Zelle- a payment program that enables instant, real-time money transfers through your bank and the Mass Violence Survivors Fund's preferred payment method
- Check - A check mailed to you for the deposit, which may take an addition 3 to 4 weeks to receive due to processing time
Minors and Applicants receiving income-based government assistance may be ineligible to be paid via Zelle.

Information about Special Needs Trusts and Custodial Accounts:
Custodial Accounts - If you are applying on behalf of a minor who is under the age of 18, gifts from the Fund will need to be paid directly to a custodial account in accordance with Michigan state law. Any bank can set up a custodial account. In your application, you will be asked to provide the address where you would like the check to be sent and the name of the custodial account. A custodial account will typically be named something like: “Customer John Smith on behalf of Adrian Smith” or ”Custodial Account for Adrian Smith”.

Special Needs Trust - If you are receiving income-based government assistance, we recommend that you consult an attorney to set up a Special Needs Trust so none of your government benefits will be negatively affected by receiving this gift. If you happen to already have a Special Needs Trust, that Trust might be able to be used for your Fund payment.

About Zelle:

Find Zelle in the mobile banking app of your bank. Zelle is supported through many major banks. For more information about Zelle including enrollment instructions please use the following link: Zelle Enrollment Instructions

When enrolling in Zelle, you can use your email address or U.S. phone number as your Zelle identifier. If you provide this identifier on the next page of the application, funds will automatically be deposited in your bank at the time of distribution.
YesNo
UTMA Account Information

All payments to minor beneficiaries must be made to a UTMA Account
Name on the UTMA Account*
Name of the bank where teh UTMA account was opened*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Victims in this category must upload a signed, notorized Arkansas UTMA Custodian Certification form:
- Arkansas UTMA Custodian Certification form
Upload the signed, notarized Arkansas UTMA Custodian Certification Form: *

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YesNo
YesNo
YesNo
-(BCD) What is the Victim’s Zelle identifier? (the email address or U.S. phone number connected to the Victim’s Zelle account)*
This must be an email address or phone number
-(BCD) Please re-type the Victim's Zelle Identifier*
This must be an email address or phone number
-(BCD) Name of Custodial account (if the Victim is under 18 years of age) or name of Special Needs Trust*
Please provide the name on the Victim’s custodial account that will be receiving the funds. If the Victim is over the age of 18, please type the full name of the Bank Account.
-(BCD) Please enter a physical address, including the city, state, zip code where you would like the check to be sent. Be sure to include all relevant information.*
This must be physical address. Please include zip code, state and all relevant information.
Later in this application, you will be asked to provide Zelle payment information for each beneficiary. Please click 'Next' below to continue.

Applicant Certification
Please read and respond to the following paragraph.

I hereby certify that all information in this application is true and accurate to the best of my knowledge. Submission of this Application for Benefits does not constitute a waiver of any legal rights. Further, I understand that any false statements made in connection with this application will be forwarded to the appropriate law enforcement agencies for possible investigation.
Yes, I certify
Please sign your name in the “Signature” box below using your mouse cursor. If you are under the age of 18, a parent or guardian must sign in the box for you.
Signature*

Clear

Application Submission
If there are any other documents you would like to submit, please upload them below.(optional)

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Clicking “Submit” below will complete your application and send it to the Fund Administrators. You will receive an email notification that your application has been received. NOTE: If you do not receive the email, please check your SPAM folder. Once the Fund Administrators have reviewed your application, you will be notified of any issues or deficiencies, or that your application has been approved.
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Fordyce Survivors Response Fund - Application for Benefits

Applicant's Contact Information

Relationship

Qualifying Questions

The following qualifying questions only apply to Death Applications

Payment Information

UTMA Account Information

Applicant Certification

Beneficiary Information

Application Submission