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                                              REMEMBER MY NAME

The National Coalition Against Domestic Violence (NCADV), in conjunction with Ms. Magazine, started this project in 1994 to create a national registry of names to increase public awareness of domestic violence deaths. Since then, NCADV has continued to collect information on incidents of women who have been killed by an intimate partner and produces a poster each year for Domestic Violence Awareness Month listing the names of those submitted. We are hoping to create as complete a registry as possible of women who have lost their lives due to domestic violence. If you know of a woman who was killed due to domestic violence, please complete this form.

         
ATTENTION: Due to the large number of submissions we receive for this project, we ask that you restrict your submittal to this form only. While we honor each victim's story and struggle, we do not have the resources to review or respond to them. Please submit your form for inclusion on this year's Remember My Name poster by May 1st. Thank you.

An asterisk (*) indicates a required field.

 

         
Victim Name:   First*   Middle   Last*
Pregnant*:
Age at Time of Death*:
Date of Death*: (format MM-DD-YYYY)
City:
State*:
Perpetrator's Name*:
Perpetrator's Age:
Relationship to Victim*:
Weapon Used:
Cause of Death:

 
Case Pending*: (Select Yes if perpetrator has not been convicted as of submission date.)
 
Murder/Suicide:

Charge: (Limit: 100 characters)

Sentence (if known):     (Limit: 100 characters)

Additional Victims:
Victim Two's Name:   First   Middle   Last Age: Pregnant:
Victim Three's Name:   First   Middle   Last Age: Pregnant:
Victim Four's Name:   First   Middle   Last Age: Pregnant:
Victim Five's Name:   First   Middle   Last Age: Pregnant:
Victim Six's Name:   First   Middle   Last Age: Pregnant:
Victim Seven's Name:   First   Middle   Last Age: Pregnant:

Witnesses: Number of Surviving Children:  
Please check all that apply to this particular case:
Custody Issues Involved Record of Prior Abuse
Prior Shelter Contact Drugs/Alcohol Involved
Prior Police Contact Restraining Order Issued
 
Comments: (Limit: 1000 characters)

Information Provided By:   (Your name will not be released without prior consent.)
Your Name: Relationship: (Please specify to whom.)
Address: City: State:
Zip: Phone: Email: