Application Form THE TEAL RIBBON FUND: Supporting Survivors of Sexual Violence Page 1 ELIGIBILITY- In order to be eligible to apply for the Teal Ribbon Fund, the applicant must meet the following criteria: ● The applicant must be a survivor/victim of sexual violence (i.e. rape, sexual assault, sexual harassment, etc.) or a North Carolina service provider for survivors/victims of sexual violence. For a list of our state’s rape crisis programs, please see ● The applicant must have exhausted all community means and resources available (including resources from the local rape crisis center) before seeking assistance from the Teal Ribbon Fund. Proof of efforts are not a requirement for application, though they may be requested by the Fund Review Committee. SPECIFICATIONS- Funds will be allocated in the following manner: ● Only NCCASA will have access to survivor/victim information. This information will be kept strictly confidential and will not be shared with other agencies, organizations or individuals. ● If the applicant is approved to receive funding, funds will be distributed directly to the company or agency where money is owed. ● This fund provides for immediate crisis needs that arise after and/or as a direct result of a sexual assault. Assistance provided by this fund is not long term or ongoing. ● The fund can provide relief in the areas of survivor/victim support* and survivor/victim services*. *“Survivor/Victim support” would include, but is not limited to: assistance with housing or relocation expenses, assistance with bills that the survivor/victim cannot pay, or other circumstances related to the assault. *“Survivor/Victim services” would include, but are not limited to: care, such as advanced counseling/therapy, or providing a retainer for a civil attorney to assist the survivor/victim. CONTACT INFORMATION- For additional contact information visit the NCCASA website at or call: 919-871-1015 . Please send completed application and original bill(s) (or if not available, a copy of the bill(s)) to: Teal Ribbon Fund NCCASA 811 Spring Forest Road Suite 100 Raleigh, NC 27609 Application Form THE TEAL RIBBON FUND: Supporting Survivors of Sexual Violence Page 2 THIS APPLICATION WAS FILLED OUT BY A: ____ Survivor ____ Sexual Assault Service Provider on behalf of a survivor/victim ____ Other (please explain below) ____________________________________________________________________ About the survivor/victim: SURVIVOR NAME: _____________________________________________________ ADDRESS: ___________________________________________________________ COUNTY: ____________________________________________________________ PHONE: ______________________________________________________________ EMAIL ADDRESS: ______________________________________________________ OTHER: ______________________________________________________________ THE BEST WAY TO CONTACT: ___________________________________________ About the local service provider: PROGRAM NAME: ____________________________________________________ STAFF CONTACT NAME: _______________________________________________ POSITION: ___________________________________________________________ ADDRESS: _________________________________________________________ COUNTY: ____________________________________________________________ OFFICE PHONE: _______________________________________________________ EMAIL ADDRESS: _____________________________________________________ OTHER: _____________________________________________________________ THE BEST WAY TO CONTACT: __________________________________________ Application Form THE TEAL RIBBON FUND: Supporting Survivors of Sexual Violence Page 3 Amount Requested: $___________ Funds will be used for: ____ Assistance with housing expenses, such as moving or relocation expenses, rent, or utilities ____ Assistance with bills resulting from the sexual violence perpetration that the victim/ survivor is unable to pay ____ Assistance with medical expenses ____ Legal representation ____ Other (please explain) ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Please briefly inform us of other avenues of assistance sought and the responses you received: ______________________________________________________________________ _________________________

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