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Confirmation 0% Complete # __Line Separation Requests under the Safe Connections Act__ The Safe Connections Act (SCA) helps “__survivors__” of domestic violence or another __“covered act__” separate their line(s), the line(s) of individuals in their care, or an alleged abuser’s line(s) from a shared account. - A “__survivor__” under the SCA is an individual who is at least 18 years old and who is either (1) a person against whom a “covered act” has been committed or allegedly committed, or (2) a person who cares for another individual against whom a “covered act” has been committed or allegedly committed. - A "__covered act__" includes conduct that constitutes domestic violence, dating violence, sexual assault, stalking, trafficking, child abuse, elder abuse, or a similar offense that is committed against the survivor or someone within the survivor’s care. To request a line separation under the SCA, please complete this form to the best of your ability and provide the required supporting documentation. Once your request is submitted, a specialized T-Mobile team will contact you using the preferred contact method you provide on this form. You will not be required to pay a fee or penalty for separating a line under the SCA.   If your request is approved, the specialized team will notify you of when the line separation will occur. __Please note__ that when a line is separated from a shared account, the Primary Account Holder will receive an automatic standard notification of a change to the account.  If the Primary Account Holder is the individual who committed the covered act, the specialized team will notify you of the expected timing of that notification so you have the opportunity to plan accordingly and ensure your safety.  \* Required Fields # __Survivor Self-Attestation__ Please review the information above and check the boxes that apply to you below. By checking a box below, you certify that the following statement is true. I am a survivor under the SCA. I am seeking a line separation because a “covered act” has been committed against me. I am seeking a line separation because a “covered act” has been committed against someone in my care. I am a New York resident. Survivor’s Information Create new account Join existing account Provide your name and contact information: First Name Last Name Email How do you prefer to be contacted? Email Phone Phone number Additional phone number(s) of dependents under your care to be released Add a phone number X Select an optionParentChild Or DependentOther Configuration - Max number of dependent phone numbers I attest and certify, under the penalty of perjury, that the phone numbers listed above are used by individuals in my care. Abuser's Information   Provide the alleged abuser’s name and phone number below: First Name Last Name Phone Number __Upload your additional supporting materials\*__ The SCA requires you to provide documentation to support your line separation request.  Please provide documentation from one of the categories listed below that shows a person on the shared account committed or is alleged to have committed a covered act against you or someone in your care: - Signed affidavit from (1) a licensed medical or mental health care provider; (2) a licensed social worker; (3) a victim services provider; or (4) an employee of court, acting within the scope of employment; - Police report or statements provided by police to magistrates or judges; - Charging documents; - Protective or restraining orders; - Any other official record that documents the covered act. __Please attach the documentation below (Optional for New York Residents):__ Attachments (0) Select a file to uploadMaximum file size allowed is 1MB. Configuration - Maximum Attachment File Count Configuration - Maximum File Size Allowed Text I certify under the penalty of perjury that I have personal knowledge of the facts stated in this Attestation and I have authority to make this Attestation on behalf of myself. I further certify, to the best of my knowledge, all of the statements and representations made in this Attestation are true and correct. I understand that any false statements or misrepresentations could subject me, personally to penalty. If you are experiencing financial hardship, you may qualify for up to six months of emergency communications support through the Lifeline Program. For information about eligibility and enrollment, visit [www.lifelinesupport.org](http://www.lifelinesupport.org/) or let our team know that you would like additional information. Domestic Violence Form # __Something went wrong. Please try again.__ # Signature Form Signature Step Loading document... # Confirmation Thank you for your submission. A dedicated member of our CARE team will call you to gather more information.  Here’s what you can expect to provide: - New account owner phone number. - Account owner’s verbal consent. __Additional resources:__   __National Domestic Violence Hotline__ __1-800-799-SAFE (7233) or visit their website at [www.thehotline.org](https://www.hotline.org).__   __National Network to End Domestic Violence__  __[www.nnedv.org](https://www.nnedv.org) for more information.__   __Find a local [domestic violence shelter near you](https://www.domesticshelters.org/help#?page=1) if you need shelter or any other assistance.__ # Confirmation Thank you for your submission. A dedicated member of our CARE team will call you to gather more information. Here’s what you can expect to provide: - SSN - Driver’s license number - 6-15 digit account PIN Note: A credit check will be run prior to the new activation. __Additional resources:__   __National Domestic Violence Hotline__ __1-800-799-SAFE (7233) or visit their website at [www.thehotline.org](https://www.thehotline.org).__   __National Network to End Domestic Violence__  __[www.nnedv.org](https://www.nnedv.org) for more information.__   __Find a local [domestic violence shelter near you](https://www.domesticshelters.org/help#?page=1) if you need shelter or any other assistance.__ Clear Form Continue ## Hello! Want to stay logged in? 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