ALMOST LOST IN THE SYSTEM INCORPORATED
Victim's Injustice Program
Client Assistance & Advocacy Application
A 501(c)(3) Nonprofit Community-Based Organization
Program Established: July 2021
CONFIDENTIAL APPLICATION
Mission Statement
The Victim's Injustice Program exists to advocate, educate, empower, and connect individuals and families affected by injustice with supportive resources, advocacy, referrals, and community partnerships while promoting fairness, accountability, and equal opportunities for all. (Almost Lost In The System)
APPLICANT INFORMATION
Full Name
Date of Birth
-
Month
-
Day
Year
Date
Age
Gender
Male
Female
Non-Binary
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Prefer Not to Answer
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone
Format: (000) 000-0000.
Secondary Phone
Format: (000) 000-0000.
Email Address
example@example.com
Preferred Method of Contact
Phone
Text
Email
Emergency Contact
First Name
Last Name
Relationship
Phone
Format: (000) 000-0000.
HOUSEHOLD INFORMATION
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Number of Adults
Number of Children
Do you currently have custody of minor children?
Yes
No
Are any children involved in this case?
Yes
No
If yes, please explain.
TYPE OF ASSISTANCE REQUESTED
Please check all services you are requesting.
Services Requested
Victim Advocacy
Criminal Justice Advocacy
Civil Rights Advocacy
Community Resources
Case Review
Case Investigation Referral
Court Support
Family Support Services
Legal Resource Referrals
Mental Health Resources
Behavioral Health Resources
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Crisis Intervention
Housing Resources
Workforce Development
Employment Resources
Educational Resources
Youth Services
Reentry Services
Record Restriction Information
Pardon Information
Community Mediation
Other
TYPE OF INJUSTICE
Please select all that apply.
Wrongful Arrest
Wrongful Conviction
Excessive Sentencing
Police Misconduct
Judicial Misconduct
Prosecutorial Misconduct
School System
Department of Juvenile Justice
Department of Corrections
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Civil Rights Violation
Housing Discrimination
Employment Discrimination
Domestic Violence
Elder Abuse
Child Abuse
Identity Theft
Fraud
Financial Exploitation
Human Trafficking
Bullying
Other
INCIDENT INFORMATION
Date Incident Occurred
-
Month
-
Day
Year
Date
City/County
Agency or Organization Involved
Case Number (If Applicable)
Has the incident been reported?
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Yes
No
If yes, to whom?
DESCRIPTION OF YOUR SITUATION
Please describe what happened and why you are requesting assistance.
CURRENT NEEDS
Please check all that apply.
Food
Housing
Transportation
Medical Assistance
Counseling
Utility Assistance
Childcare
Employment
Financial Assistance
Legal Assistance
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Victim Compensation Information
Safety Planning
Advocacy
Other
DOCUMENTS AVAILABLE
Please check any documents you currently have.
Police Report
Court Documents
Medical Records
Photographs
Witness Statements
Videos
Emails
Text Messages
Audio Recordings
Social Media Evidence
Employment Records
School Records
Other
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ADDITIONAL SERVICES
Would you like information about:
Would you like information about:
Workforce Development
Housing Resources
Reentry Services
Youth Development Programs
Behavioral Health Services
Educational Resources
Community Partnerships
Volunteer Opportunities
Membership Opportunities
CONFIDENTIALITY
I understand this application is confidential.
I understand submitting this application does not guarantee legal representation, financial
assistance, or acceptance into any program.
I certify that the information I have provided is true and accurate to the best of my knowledge.
Applicant Signature
Date
-
Month
-
Day
Year
Date
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PHOTO/MEDIA RELEASE (OPTIONAL)
I authorize Almost Lost In The System Incorporated to photograph, video record, or share my story for educational or advocacy purposes.
Permission for photo/media release
Yes
No
Signature
STAFF USE ONLY
Date Received
Staff Member
Application Number
Program Assigned
Priority Level
Priority Level Options
Emergency
High
Medium
Low
Eligibility
Approved
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Pending
Denied
Case Manager
Referral Source
Follow-Up Date
Case Notes
REQUIRED DOCUMENTS (IF AVAILABLE)
Government-issued Photo Identification
Police Report (if applicable)
Court Documents (if applicable)
Medical Records (if applicable)
Supporting Evidence
Any additional documentation related to the request
This application reflects the advocacy-centered mission of your Victim's Injustice Program and is designed to help your staff gather the information needed to assess requests for assistance while protecting applicants' privacy.
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