MOVA – Massachusetts Office for Victim Assistance

Commemorated Person's Information

Victim's Name(Required)

First Last

Write below how you wish the name to appear on the engraving. In addition to first and last names, you may also include a middle name/initial, nickname, and/or suffix.(Required)

To ensure accurate spelling please confirm above how you wish the name to appear on the engraving. In addition to first and last names, you may also include a middle name/initial, nickname, and/or suffix.(Required)

Yes, the accurate spelling of the name is entered into the box above.

Date of Birth(Required)

MM

DD

YYYY

Date of Death(Required)

MM

DD

YYYY

Commemorated Person’s Victim’s Connection to Massachusetts (check all that apply)(Required)

Birthplace

Place of homicide

Current or former residence

Family/survivor's residence

Applicant's Information

Applicant's Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Applicant’s Relationship to Victim - I am the ...(Required)

Parent/Guardian

Sibling

Grandparent

Spouse/Partner

Child