Emergency Financial Assistance Fund Application Page 2
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2TIPS FOR COMPLETING EMERGENCY FINANCIAL ASSISTANCE APPLICATION
Date of Request
Please be sure to record date the application is actually sent to SCVAN for approval. Do not back date!
Type of Need
Food: Please be sure to “X” which store, BL (Bi-Lo) or FL (Food Lion) and include the store number.
Example –
____BL # ________ OR ____FL # ________
X
158
Without this information, it will delay processing of the application.
Prescriptions: List the names of the drugs requested in the description area OR attach copies of the
prescriptions to the application. Choose a Rite Aid that’s nearest the victim and include the store number OR
if it’s not a Rite Aid, choose Another Pharm.
Example –
X
45784
_____RA # _________ OR _____Another Pharm.
Without this information, it will delay processing of the application.
Date of Crime /County of Crime:
Please do not leave these blank!
Was the Crime Reported/Incident Report Available
Please let me know if the crime was reported or not. All reported crimes must have an incident report! If
crime was not reported, please give description of crime events in designated area.
Number of primary/secondary victims that services will assist
VERY IMPORTANT: Include number of all persons in household (or that are directly affected by crime). This
is needed for grant purposes AND to determine eligibility amount for food requests.
Applicant’s Information
Victim’s Information. Please provide full social security number for prescription requests ONLY. All
other requests, include last 4 of social security number. Include date of birth for all requests .
If the victim is deceased, please use next of kin as applicant.
Victim Assistance Provider
Advocate’s Information. Make sure to include your phone number and email address (if you have one)
Please read disclosure, sign and date application
.
IMPORTANT NOTES:
Victim’s signature is not required.
Approvals/Denials will be sent via email (please add
to safe senders list)
.
Please call or email before sending an application
Incomplete applications will not be approved!
If you need assistance with completing the emergency fund application, please
call Nicole Goodwin 803-750-1200 or email: .
NEW!
Submit all applications via email:
Or fax: 1.866.473.1272
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Parent category: Business