Wufoo

1) Name of January 6 Defendant. * First Last
2) What is your relationship to the January 6 Defendant?
Date of suicide. MM / DD / YYYY
a) Upload death certificate

Upload file:
3) What events preceded/caused the suicide?
4) What costs were associated with the death/funeral of the January 6 defendant? (Upload related documents)
Amount $ Dollars . Cents
Attach a File
Attach a File
Attach a File
5) Was money confiscated by the government from Give-Send-Go or other crowd-funding account(s) associated with the January 6 defendant established to assist family members or to cover defendant’s legal fees?
Yes No
a) List accounts, and amount of fines.

Account:
Amount $ Dollars . Cents
Account:
Amount $ Dollars . Cents
Account:
Amount $ Dollars . Cents
b) Upload supporting documents (Proof of account total/Fine amount)

Attach files:
Attach files:
Attach files:
6) Were you harassed, threatened, censored on social media platforms due to your relationship with the January 6 defendant? (Yes/No)
Yes No
7) Were you harassed, doxed, or threatened as a result of media coverage associated with the January 6 defendant? (Yes/No)
Yes No
8) Were you forced to relocate due to harassment because of your relationship to the January 6 defendant? (Yes/No)
Yes No
9) If you have children, were the children harassed due to their relationship to the defendant? (Yes/No)
Yes No
10) Were your children forced to transfer schools or receive homeschooling due to their relationship to the January 6 defendant? (Yes/No) (Upload any associated documents)
Yes No
Attach a File
Attach a File
11) Did you (or your children) have to undergo (or are currently undergoing) counseling to deal with the suicide of the January 6 defendant? (Yes/No) (Upload corresponding documents, bills, etc.)
Yes No
Attach a File
Attach a File
12) Have you lost your job or business because of your relationship to the January 6 defendant? (Yes/No)
Yes No
13) Have you lost your home and/or vehicle(s) due to the legal expenses associated with the January 6 defendant? (Upload related documents)
Yes No
Attach a File
Attach a File
14) Were you evicted from rental property due to your relationship to the January 6 defendant? (Upload related documents)
Yes No
Attach a File
Attach a File
15) How much have you paid in legal fees for the defense of the January 6 defendant? (Upload corresponding documents)

Amount: $ Dollars . Cents
Attach a File
Attach a File
16) Do you still owe money for attorney fees related to the defense of the January 6 defendant? (Upload related documents)

Amount: $ Dollars . Cents
Attach a File
Attach a File
Name First Last
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