Reginald Archibald
Boy Scouts
Catholic Church
Archdiocese of New York
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Rochester Diocese
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Youth Orgs
About Us
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In the News
Child Victims Act Information
Contact Us
Reginald Archibald
Boy Scouts
Catholic Church
Archdiocese of New York
Albany Diocese
Brooklyn Diocese
Buffalo Diocese
Ogdensburg Diocese
Rochester Diocese
Rockville Centre Diocese
Syracuse Diocese
Youth Orgs
About Us
Attorneys
In the News
Child Victims Act Information
Contact Us
Step
1
of
19
5%
Thank you for taking the time to provide the information requested in this online questionnaire. We will use this information in our negotiations and to aid our investigation regarding your claim.
Please do not guess or feel compelled to provide answers to questions if you do not know the answer. For example, if for some reason you cannot recall exact dates, please give us your best estimate and let us know that you do not recall specific dates. And please do not be alarmed if you cannot recall the dates as we will likely have other ways to obtain the dates. We understand that you will likely recall more information as time goes on, so please only provide the best information that you can today. You are always welcome to share more information with us, and we will likely have the opportunity to provide more information down the road.
We are providing this form because some people find it easier to provide the information in this fashion. Please let us know if you would rather provide this information over the phone.
Please know that the information you provide to us will be kept confidential and will not be shared with anyone else.
Name
Mr.
Ms.
Dr.
Prof.
Rev.
Prefix
First
Middle
Last
Date of Birth
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1923
1922
1921
1920
Social Security Number
Current Marital Status
Married
Single - Never Married
Single - Divorced
Singled - Spouse Deceased
How many years married?
Less than 1
1
2
3
4
5
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70
Do you have any children, including: biological, adopted, or stepchildren?
Yes
No
How many children?
1
2
3
4
5
6
7
8
9
10
11
12
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19
20
What are the full names of your parents and/or guardian(s) at the time of the abuse?
First
Last
Are your parents or your other guardian(s) at the time of the abuse alive?
Yes
No
Would you be comfortable with us talking with your parents about the abuse if we first talked with you before reaching out to them?
Yes
No
Do you have any siblings?
Yes
No
List
Sibling First Name
Sibling Last Name
Sibling Birthdate
Deceased?
Yes
No
Would you be comfortable with us talking with your sibling(s) about the abuse if we first talked with you before reaching out to them?
Yes
No
This field is hidden when viewing the form
Residence History
Please list all your places of residence since birth and indicate the duration of residency for each
Address Line 1
Address Line 2
City
State
Zip
Residence Start Month
Residence Start Day
Residence Start Year
Residence End Month
Residence End Day
Residence End Year
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
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31
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
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2
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25
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29
30
31
Residence History
Please list all your places of residence since birth and indicate the duration of residency for each
Address Line 1
Address Line 2
City
State
Zip
Residence Start Date
Residence End Date
State and Federal Assistance
Yes
No
This field is hidden when viewing the form
State and Federal Assistance History
Have you ever seen, consulted with, or received assistance of any sort from any federal, state, or local social welfare, vocational, rehabilitation or service agency, including Medicare or Medicaid?
Agency Name
Agency Address Line 1
Agency Address Line 2
Agency City
Agency State
Agency Zip
Agency Start Month
Agency Start Day
Agency Start Year
Agency End Month
Agency End Day
Agency End Year
Names of People Who Worked With You
Nature of the Services Provided by the Agency
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
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Jan
Feb
Mar
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May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
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14
15
16
17
18
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20
21
22
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24
25
26
27
28
29
30
31
State and Federal Assistance History
Have you ever seen, consulted with, or received assistance of any sort from any federal, state, or local social welfare, vocational, rehabilitation or service agency, including Medicare or Medicaid?
Agency Name
Agency Address Line 1
Agency Address Line 2
Agency City
Agency State
Agency Zip
Agency Start Date
Agency End Date
Names of People Who Worked With You
Nature of the Services Provided by the Agency
Have you ever filed for bankruptcy?
Yes
No
When did you file For bankruptcy?
Month
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
Day
1
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Year
Year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
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1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
In what state did you file for bankruptcy?
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
What bankruptcy chapter did you file under?
Ch. 7
Ch. 11
Ch. 13
Other
Please Explain
If you filed for bankruptcy jointly or for a business, please state the name(s) of the other person(s)/business(es):
What was the amount of discharge received, if any?
What is your highest level of education?
Left High School Before Graduation
High School Graduation
GED
2-Year College
4-Year College
Post-Graduate Degree
Other
Please Explain
Please list your complete educational background, including high school, college, university, graduate, trade or vocational schools, and/or correspondence classes as well as any professional licenses held.
Type of School
School Name
School Address Line 1
School Address Line 2
School City
School State
School Zip
School Start Date
School End Date
Type of Degree or Certification Received
Elementary School
Middle School
Junior High School
High School
College/University
Graduate School
Trade School
Are you employed?
Yes
No
Current Employer
Name
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Employment Start Date
Month
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Your Position
Your salary or rates of compensation
Your benefits
The names of your supervisor(s)
First Name
Last Name
This field is hidden when viewing the form
Please list your complete educational background, including high school, college, university, graduate, trade or vocational schools, and/or correspondence classes as well as any professional licenses held.
Employer Name
Employer Address Line 1
Employer Address Line 2
Employer City
Employer State
Employer Zip
Position
Salary or Rates of Compensation
Benefits
Name(s) of your Supervisor(s)
Employer Start Month
Employer Start Day
Employer Start Year
Employer End Month
Employer End Day
Employer End Year
Reason for Leaving
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
List your complete employment history
Employer Name
Employer Address Line 1
Employer Address Line 2
Employer City
Employer State
Employer Zip
Position
Salary or Rates of Compensation
Benefits
Name(s) of your Supervisor(s)
Employer Start Date
Employer End Date
Reason for Leaving
Type of Case
Church Non-Catholic
Foster Care
School
Other
In which state did the abuse primarily occur?
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Did the abuse occur in any other states?
Yes
No
Which other state(s) did abuse occur?
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Info about the abuser(s)
Name
How would you describe the abuser’s physical appearance?
To your knowledge, is the abuser still alive?
What was the role of the abuser(s)?
Yes
No
Teacher
Student
Other
Info about the abuser(s)
Name
How would you describe the abuser’s physical appearance?
To your knowledge, is the abuser still alive?
What was the role of the abuser(s)?
Yes
No
Pastor
Deacon
Usher
Lay Person
Info about the abuser(s)
Name
How would you describe the abuser’s physical appearance?
To your knowledge, is the abuser still alive?
Yes
No
Info about the abuser(s)
Name
How would you describe the abuser’s physical appearance?
What was the role of the abuser?
To your knowledge, is the abuser still alive?
Yes
No
Where did the abuse occur?
What was the name and address of the school?
Name
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Did the abuse take place on the grounds of a foster home or other foster care agency facility?
Yes
No
If you remember it, please state the name of the facility or the address of the home where the abuse took place
Name
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
If you remember it, please state the name of the agency or agencies that placed you in the foster home or other facility where the abuse took place:
What is/was the name and address of the church where the abuse took place?
Name
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Is the church affiliated with any larger denomination/sect?
Did the abuse occur on the grounds of the school?
Yes
No
Where did the abuse occur?
Did the abuse occur during a school activity?
No
Yes
What was the nature of the home or facility where the abuse took place?
Residential foster home
Group home
Juvenile detention facility
What was the role of the abuser?
Foster parent
Foster sibling
Did CPS or any other agency intervene because of the abuse
Yes
No
Please indicate which agency
What action did CPS or other state agency take regarding the abuse?
Some religious leaders have their assignments moved, including transfers as a result of child abuse. We will work to find this information, but please let us know if you believe your abuse may have involved more than one Church, such as a person who was transferred from another Church or school before they abused you. Did the abuse involve more than one Church/entity?
Yes
No
Which one(s)?
Is the Church affiliated with a school or university?
Yes
No
What was the name and address of the school?
Name
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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Maryland
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Northern Mariana Islands
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Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Do you believe you know the approximate date, month, or year that you believe he or she first abused you? We know this may be difficult to remember, so please do not guess. If you cannot approximate, please check “I am not sure.”
I believe I can approximate the date of the first inappropriate encounter
I believe I can approximate the month of the first inappropriate encounter
I believe I can approximate the year of the first inappropriate encounter
I am not sure
Date
Month
Month
1
2
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Day
Day
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Year
Year
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1925
1924
1923
1922
1921
1920
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
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1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
How many times do you believe he or she acted inappropriately with you? We realize this may be difficult to remember, or to know with certainty, so please just answer to the best of your memory.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25 or more
Do you believe you know the approximate date, month, or year that you believe he or she last did anything inappropriate with you? Again, we know this may be difficult to remember, so please do not guess. If you cannot approximate the last time you believe he or she may have done something inappropriate with you, please pick “I am not sure.”
I believe I can approximate the date of the last inappropriate encounter
I believe I can approximate the month of the last inappropriate encounter
I believe I can approximate the year of the last inappropriate encounter
I am not sure
Date
Month
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
If you are comfortable sharing this information, please select each of the inappropriate things that you recall him or her doing to you. We know this is difficult to provide, but we need this information to help try to resolve your claim.
He or she removed my clothes
He or she asked me to remove my clothes
He or she took naked pictures of me
He or she touched my breasts over clothing
He or she touched my breasts under clothing
He or she touched my buttocks over clothing
He or she touched my buttocks under clothing
He or she touched my genitals over clothing
He or she touched my genitals under clothing
He or she asked me to masturbate
He or she asked me to masturbate him or her
He or she asked me to touch him or her in a sexual way
He or she had me perform oral sex on him or her
He or she performed oral sex on me
He or she had sexual intercourse with me
Other
To the best of your ability, describe the nature and extent of the sexual abuse:
Was anyone ever present during any of the conduct that you identify above?
Yes
No
I can't remember
Who was present?
My Parent(s)
Another Student
Another Church Leader
Another Usher
Another Lay Person
Another Person who Worked at the Church
A Deacon
A Sibling
Other
Who was present?
My Parent(s)/Foster Parent(s)
Another Student
Another Foster Child
Court Appointed Special Advocate (CASA)
A religious figure
An Employee of the group home/facility
A friend
A Sibling
Other
Who was present?
My Parent(s)/Guardian(s)
Another Student
Another Teacher
An Employee of the school
A friend
Other
Who else was present?
If you know, how and why did the abuse come to an end?
How do you think the abuse has affected you and impacted your life? Please check any of the following issues that may apply. In addition, feel free to write a response in your own words by selecting “other.”
Anxiety
Academic (Poor performance in school)
Anger
Attempted Suicide
Depression
Flashbacks
Guilt
Hypervigilance
Marriage Problems (e.g. Divorce)
Nightmares
Problems with Anxiety
Professionally (Failure to reach full potential)
Sexual Dysfunction
Sexual Intimacy problems
Shame
Sleep Problems
Substance Abuse
Suicidal Thoughts
Trust Issues
Other
In your own words, please describe how the abuse has affected you and impacted your life.
We normally must prove the Church knew or should have known that the person who abused you posed a danger to children. Although the Church may now admit that the person was an abuser, the Church may not be legally responsible for what happened to you unless we can show the Church knew or should have known that you were in danger before or during the time you were abused. We refer to this as “notice evidence” and it is critical evidence for your case – without it we may not be able to prove your case. These questions are designed to help us find such “notice evidence.”
We normally must prove that the foster care agency or the state knew or should have known that the person who abused you posed a danger to children. Although the foster care agency or the state may now admit that the person was an abuser, the foster care agency or the state may not be legally responsible for what happened to you unless we can show that they knew or should have known that you were in danger before or during the time you were abused. We refer to this as “notice evidence” and it is critical evidence for your case – without it we may not be able to prove your case. These questions are designed to help us find such “notice evidence.”
We normally must prove that the school knew or should have known that the person who abused you posed a danger to children. Although the school may now admit that the person was an abuser, the school may not be legally responsible for what happened to you unless we can show the school knew or should have known that you were in danger before or during the time you were abused. We refer to this as “notice evidence” and it is critical evidence for your case – without it we may not be able to prove your case. These questions are designed to help us find such “notice evidence.”
We normally must prove that an entity knew or should have known that the person who abused you posed a danger to children. Although the Defendant may now admit that the person was an abuser, the Defendant may not be legally responsible for what happened to you unless we can show the Defendant knew or should have known that you were in danger before or during the time you were abused. We refer to this as “notice evidence” and it is critical evidence for your case – without it we may not be able to prove your case. These questions are designed to help us find such “notice evidence.”
Can you think of any reasons why someone else might have known or suspected that you were being abused? For example, did anyone see you spending too much time alone with the abuser, or did someone see you with the abuser after hours or in a place where children were not normally allowed to go?
Yes
No
Why do you think someone else might have known or suspected that you were being abused?
Can you think of anyone else who may have been abused by the same person?
Yes
No
Who do you think may also have been abused by the same person?
We know that most children do not ever tell anyone about sexual abuse, but when you were a child did you ever tell anyone that you did not like the perpetrator or that (s)he had done something inappropriate to you?
Yes
No
Who did you tell and what did you tell them?
Name of Person You Told
Approximate Year You Told Them
What Did You Tell Them?
Please do your best to compile a list of all people you remember having possible contact with the perpetrator, even if you don’t think they were abused by the perpetrator.
Name
Position
Do you believe that anyone else may have ever complained about abuse or inappropriate behavior by the person who abused you? If any, please list why you believe the person complained.
Name of Person
Why You Believe They Complained
Do you have a yearbook or roster from the Church/school or are you able to get one?
Yes
No
Do you recall whether the Church issued a directory or photo directory to members?
Yes
No
Do you have a directory?
Yes
No
Do you currently have any records from your time at the school, such as report cards, rosters, or letters to or from employees of the school?
Yes
No
Please email call Jessica Burrus at jessicab@pcvalaw.com to let her know you have these records. We may interview other children because they may have complained about the abuser or they may know of someone else who complained about the abuser. Please do NOT reach out to potential witnesses on your own.
Do you have any yearbooks or other records from the time period when you were abused that might have the names of other kids who were your same age?
Yes
No
Please email call Jessica Burrus at jessicab@pcvalaw.com to let her know you have these records. We may interview other children because they may have complained about the abuser or they may know of someone else who complained about the abuser. Please do NOT reach out to potential witnesses on your own.
Please think hard about this question. These types of records can help us identify other witnesses who may have complained about your abuser. If you know of someone who may have these types of records, please email Jessica Burrus at jessicab@pcvalaw.com so that we can try to obtain them.
Please immediately email Yemi Ajayi at yajayi@pcvalaw.com and let him know you have these records. We may interview other children because they may have complained about the abuser or they may know of someone else who complained about the abuser. Please do NOT reach out to potential witnesses on your own.
Please think hard about this question. These types of records can help us identify other witnesses who may have complained about your abuser. It is OK if you do not have these types of records, but please give it some hard thought. If you know of someone who may have these types of records, please email Yemi Ajay at yajayi@pcvalaw.com and let him know so that we can try to obtain them.
Please immediately email Tim Brothwell at tbrothwell@pcvalaw.com and let him know you have these records. We may interview other children because they may have complained about the abuser or they may know of someone else who complained about the abuser. Please do NOT reach out to potential witnesses on your own.
Please think hard about this question. These types of records can help us identify other witnesses who may have complained about your abuser. It is OK if you do not have these types of records, but please give it some hard thought. If you know of someone who may have these types of records, please email Tim Brothwell at tbrothwell@pcvalaw.com and let him know so that we can try to obtain them.
Please immediately email Tim Brothwell at tbrothwell@pcvalaw.com and let him know you have these records. We may interview other children because they may have complained about the abuser or they may know of someone else who complained about the abuser. Please do NOT reach out to potential witnesses on your own.
Please think hard about this question. These types of records can help us identify other witnesses who may have complained about your abuser. It is OK if you do not have these types of records, but please give it some hard thought. If you know of someone who may have these types of records, please email Tim Brothwell at tbrothwell@pcvalaw.com and let him know so that we can try to obtain them.
Do you your parents or siblings have yearbooks or other records from the time period when you were abused that might have the names of other kids who were your same age?
Yes
No
Please email Jessica Burrus at jessicab@pcvalaw.com to let her know you have these records. We may interview other children because they may have complained about the abuser or they may know of someone else who complained about the abuser. Please do NOT reach out to potential witnesses on your own.
Please think hard about this question. These types of records can help us identify other witnesses who may have complained about your abuser. It is OK if you do not have these types of records, but please give it some hard thought. If you know of someone who may have these types of records, please email Jessica Burrus at jessicab@pcvalaw.com so that we can try to obtain them.
Please immediately email yajayi@pcvalaw.com and let him know you have these records. We may interview other children because they may have complained about the abuser or they may know of someone else who complained about the abuser. Please do NOT reach out to potential witnesses on your own.
Please think hard about this question. These types of records can help us identify other witnesses who may have complained about your abuser. It is OK if you do not have these types of records, but please give it some hard thought. If you know of someone who may have these types of records, please email Yemi Ajayi at yajayi@pcvalaw.com and let him know so that we can try to obtain them.
Please immediately email Tim Brothwell at tbrothwell@pcvalaw.com and let him know you have these records. We may interview other children because they may have complained about the abuser or they may know of someone else who complained about the abuser. Please do NOT reach out to potential witnesses on your own.
Please think hard about this question. These types of records can help us identify other witnesses who may have complained about your abuser. It is OK if you do not have these types of records, but please give it some hard thought. If you know of someone who may have these types of records, please email Tim Brothwell at tbrothwell@pcvalaw.com and let him know so that we can try to obtain them.
Please immediately email Tim Brothwell at tbrothwell@pcvalaw.com and let him know you have these records. We may interview other children because they may have complained about the abuser or they may know of someone else who complained about the abuser. Please do NOT reach out to potential witnesses on your own.
Please think hard about this question. These types of records can help us identify other witnesses who may have complained about your abuser. It is OK if you do not have these types of records, but please give it some hard thought. If you know of someone who may have these types of records, please email Tim Brothwell at tbrothwell@pcvalaw.com and let him know so that we can try to obtain them.
Have you ever maintained a journal, calendar, or diary that refers to the events of the abuse?
Yes
No
Do you still have these materials in your possession?
Yes
No
Have you ever corresponded with anyone in writing about the abuse, including with the abuser?
Yes
No
Do you still have that correspondence in your possession?
Yes
No
Please explain the format in which you have that correspondence, for example, in the form of text messages, a letter written in reply, etc.:
Have you ever posted on social media about the abuse?
Yes
No
On which platform did you post?
Facebook
Twitter
Instagram
Other
What other platform?
Please list the dates or approximate dates of all of the posts about the abuse
Month
Day
Year
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Which accounts and posts do you still have access to?
Facebook
Twitter
Instagram
Other
What other platform?
Have you ever told anyone about the abuse?
Yes
No
To the extent that you are able, please list the names, relationships to you, contact information, and approximates dates when you told each person about the abuse. Please do NOT reach out to potential witnesses on your own.
Name
Address Line 1
Address Line 2
City
State
Zip
Phone Number
Email
Date
Relationship
Have you ever sought counseling which you now believe was directly or indirectly related to the abuse?
Yes
No
Please explain why you believe the counseling was related to the abuse:
Approximately what year did you first receive counseling?
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
Approximately how long did you participate in counseling?
Over the course of your life have you had any out-of-pocket expenses for the abuse? For example, have you paid for counseling or medication?
Yes
No
Please provide a description and dollar amount for each out-of-pocket expense you have incurred as a result of the abuse, for example, for counseling or medication.
Expense Description
Expense Amount ($ Amount)
Do you have billing records, receipts, or invoices for these expenses?
Yes
No
This field is hidden when viewing the form
Please list all physicians, therapists, psychologists, psychiatrists, medical institutions, counselors, clergy, social service organizations or other physical or mental health care providers who have ever examined or treated or consulted with you for anything related to the abuse.
Provider Name
Provider Address Line 1
Provider Address Line 2
Provider City
Provider State
Provider Zip
Provider Telephone Number
Treatment Start Month
Treatment Start Day
Treatment Start Year
Treatment End Month
Treatment End Day
Treatment End Year
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Please list all physicians, therapists, psychologists, psychiatrists, medical institutions, counselors, clergy, social service organizations or other physical or mental health care providers who have ever examined or treated or consulted with you for anything related to the abuse.
Provider Name
Provider Address Line 1
Provider Address Line 2
Provider City
Provider State
Provider Zip
Provider Telephone Number
Treatment Start Date
Treatment End Date
Do you want to file your claim?
Yes
No
Maybe
Thank you very much for taking the time to complete this questionnaire. Is there anything else that you would like us to know about your answers or about any other issue?