Fordyce Designated Funds Application
This form is to be used only by the designated beneficiary (legal heir or trustee) of the family of the deceased or if you suffered gunshot wounds in the mass shooting that took place at the Mad Butcher Supermarket in Fordyce, AR on June 21, 2024.
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Information provided will be kept confidential.
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Wounded Survivors - Skip Section III.
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Applicants for deceased victims must fill out all sections.
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If you need assistance filling out this form, please call us at 706-842-8467.
Section I: Applicant Information
Full Name (First Name, Middle Initial, and Last Name):
Current Address:
Phone:
Email:
Section II: Photo ID
Upload a valid photo ID to verify your identity. If you do not have a valid photo ID, please email us at contact@victimsfirst.org.
Section III: Victim Information
Victim's Full Name:
Victim's Date of Birth:
What is your relationship to the deceased?
At the time of death, what was the deceased's marital status?
Did the deceased victim have a will? If so, please upload.
Section IV: Beneficiary Information
Full Name of Legal Beneficiary Who Will Be Receiving the Designated Funds:
Does the beneficiary receive government assistance?
Does the beneficiary have a U.S. bank account?
Does the beneficiary want to receive the designated funds by Zelle or check?
If Zelle, please provide phone or email used for beneficiary's Zelle account:
If check, please provide the full mailing address of the beneficiary:
Section V: Signature of Claimant
By signing below (e-signature), I hereby certify, under penalty of perjury, that the information provided in this application is true and accurate to the best of my knowledge. I further state that the information provided did not originate with fraudulent intent by me or any person acting in concert with me and that the signature below is my own legal signature. I give VictimsFirst permission to contact accounts and account administrators to verify that the information I provided is true and accurate. Lastly, I acknowledge that the benefits paid by the fund are a gift to which no person has a legal claim or entitlement.
Your Application Has Been Submitted