THIS IS NOT A GOVERNMENT FORM

Private Document — Not affiliated with any U.S. federal, state, or local government agency

U.S. Reparations Survey

Created by Victor D. Dunn · Form created (9/26)

THIS IS NOT A GOVERNMENT FORM

This survey is created and administered by a private entity. It is NOT affiliated with, authorized by, or sanctioned by the United States government or any federal, state, or municipal agency. Submission does not create any government obligation.

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Section 1

— Applicant Information

Full Legal Name:

Applicant County (not mailing address):

Applicant State (not mailing address):

Phone:

Email:

Race / Ethnicity:

Section 2

— Eligibility Basis

Check all categories that apply:

Descendant of an enslaved person in the United StatesDescendant of a person subjected to race-based state or federal discrimination (1865–1968)Descendant of a person harmed by racially restrictive housing, lending, or land-seizure policiesDescendant of a person subjected to race-based violence or intimidation condoned by government inactionOther qualifying historical harm:

Section 3

— Ancestral Documentation

3A. Ancestor's Name(s)

3B. Approximate Dates of Residence or Enslavement

3C. Known Locations (Plantation, County, State)

3D. Description of Harm or Oppression Experienced

Section 4

— Evidence of State or Federal Responsibility

Describe how government policy, inaction, or enforcement contributed to the harm.

Description:

Section 5

— Family Impact Statement

Economic Impact

Housing / Land Loss

Education / Employment Barriers

Intergenerational Effects

Section 6

— Institutional Benefit Documentation (Optional)

Modeled after reparative-justice audits conducted by the University of Glasgow and the Church of England.

A. Identified Institution(s):

B. Type of Benefit Received:

C. Approximate Dates of Benefit:

D. Description of Connection to Enslavement or Racial Oppression:

Section 7

— Historical Audit Evidence (Optional)

Attach any documentation showing:

Institutional ties to slavery
Governmental profit from discriminatory systems
Land seizures or racially restrictive policies
Investments or endowments derived from slave economies

Evidence Provided:

Section 8

— Reparative Partnership or Investment Request

Select any reparative partnership or investment you are requesting:

Educational Partnership SupportCommunity Impact InvestmentBusiness or Agricultural Development FundingLand Restoration or CompensationHistorical Recognition CertificateResearch Collaboration or Archival Support

Section 9

— Requested Form of Reparative Relief

Check all categories that apply:

Financial Restitution — Proposed amount or formula:

Land Restoration or Compensation — Describe parcel or claim:

Educational Reparations — Tuition assistance, scholarships, vocational programsBusiness or Agricultural Grants — Startup or expansion supportHealthcare Equity Programs — Coverage, trauma-informed care, long-term supportOfficial Recognition / Certificate of Historical Harm

Other Relief:

Section 10

— Supporting Documents Checklist

Attach copies (not originals):

Census recordsFreedmen's Bureau documentsLand deeds or tax recordsMilitary service recordsHistorical affidavitsPhotographs, letters, oral-history transcriptsAcademic or genealogical researchLegal or property claims previously filedGenealogy tree (optional)

— Applicant Declaration

I declare that the information provided is true and accurate to the best of my knowledge.

I accept the terms of this questionnaire and authorize the voluntary submission of my information to Victor D. Dunn for review and use as described in the notices above.

Signature:

Date:

Notice of Private Entity Status

This survey is created and administered by a private entity. It is not affiliated with, authorized by, or sanctioned by the United States government or any federal, state, or municipal agency. Submission of this form does not constitute a government filing, nor does it create any government obligation.

Legal-Use Notice

Information submitted through this survey may be used, where necessary, in a legal claim against responsible parties. By submitting this form, the applicant acknowledges that the information provided may be included in legal filings, evidentiary submissions, or related proceedings intended to seek redress or accountability.

Non-Return Notice

Any information submitted through this survey will not be returned. Applicants should only provide copies of documents and retain originals for their records.

Submission Instructions

Upon completion, please mail to:

Victor D. Dunn

PO Box 41

Lindale, TX 75771

Or email to: [email protected]

You may also upload this form at victordunn.com

Share This Survey

Help spread the word — share this survey with your community on social media.

Share:Facebook 𝕏X / Twitter inLinkedIn

THIS IS NOT A GOVERNMENT FORM

Private document created by Victor D. Dunn · Not affiliated with any U.S. government agency