Urban Specialists Victims' Services Intake & Support Log

For Burial, Repast, Balloon Release, Emergency Food, and Invoice Documentation

Victim's Case Information

Case No.

Victim's Name

Representative's Name

If the Victim is living and is the representative, place "SELF" in this field

Contact Number

Date of Repast

If not a repast order and for emergency food, please place NA

Date order made:

Please check one of the following options:

Catering Service

Wal-Mart Online Order

Emergency Food

Other

Caterer Name:

Caterer Contact Number:

Amount Approved: $

If it is not a cater amount and it is a wal-mart order or other please place NA in the field.

Order Description (meals, beverages, quantity, etc.)

Wal-Mart Store Location:

Approved Amount: $

If it is not a Wal-mart order please place NA in this field.

Pickup Time:

Pickup SPACE:

Order Description (items, quantity, special notes)

Other

If it is other, please list the online grocery store or food cater information (description of order, amount, and pickup info)

Funeral home name

Payment confirmation number

Name of representative that took the payment?

Balloon Release Organization

B. Release Confirmation Number

B. Release Confirmation Amount

Relocation: Organization Name

Relocation confirmation number

Relocation Confirmation Amount:

Upload all Supporting Documents

Submitted by (Staff Name):