Wufoo

Name * First Last
102) Did you or any of your family members suffer losses (job, business, etc.) due to your arrest/conviction/incarceration/involvement in January 6?
Yes No
a) If yes, describe the losses. (Upload corroborating documents.)
Attach a File
Attach a File
103) Did you suffer physical injury during the course of your arrest/raid?
in January 6?
Yes No
a) If yes, describe the injury/injuries. (Upload corroborating documents.)
Attach a File
Attach a File
104) Did any of your family members suffer any injuries during or suffer any post-physical/mental trauma due to events surrounding the raid leading to your arrest?
Yes No
a) If yes, describe physical trauma (heart attack, miscarriage, death, PTSD, etc.). (Upload corroborating documents.)
Attach a File
Attach a File
105) Did the physical/mental trauma suffered by you and/or your family member(s) require medical/psychiatric attention/hospitalization?
Yes No
a) Describe the physical/mental trauma. (Upload corroborating documents.)
Attach a File
Attach a File
b) How much did you pay for treatment?
c) Is this treatment ongoing?
Yes No
106) Did any financial institution impose retribution upon any family member due to your involvement in January 6 (close bank account(s), terminate/refuse/cancel loan approvals, cancel/deny mortgage or car/homeowners insurance, deny/evict from rental property, etc.)?
Yes No
a) If yes, describe these actions. (Upload corroborating documents.)
Attach a File
Attach a File
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