- Identity and contact information:
– Name of the survivor
– Name of the abuser that is known to the survivor
– Contact information to be used for communications regarding the line separation request
- Information about the affected lines:
– Identify each line that should be separated and the phone number associated with that line
– Identify which line(s) on a shared account belong to the survivor and any individuals in the care of the survivor
– If separating an abuser’s line, state that the abuser is the user of that specific line
- If the line separation involves the line of an individual in the care of a survivor:
– Provide a signed and dated affidavit that states that the individual is in the care of the survivor and is the user of the specific line(s) to be separated
- If the line separation is being requested by a survivor’s designated representative:
– Provide the name of that designated representative and the designated representative’s relationship to the survivor, and state that the designated representative assisted the survivor
- Evidence that an individual who uses a line under the shared account has committed or allegedly committed a covered act against the survivor or an individual in the survivor’s care:
Provide either:
– A copy of a signed affidavit from a licensed medical or mental health care provider, licensed military medical or mental health care provider, licensed social worker, victim services provider, or licensed military victim services provider, or an employee of a court, acting within the scope of that person’s employment; or
– A copy of a police report, statements provided by police, including military or Tribal police, to magistrates or judges, charging documents, protective or restraining orders, military protective orders, or any other official record that documents the covered act.
