Form details Review & Certify Confirmation # 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 Provide your name, phone number, email address, and preferred contact method below: First Name* Last Name* Phone number* Email* How do you prefer to be contacted? * Email Phone ### Individuals in the Survivor’s Care If there are individuals in your care on the shared account and you wish to separate their lines from the shared account, please provide their phone numbers and check the box below to attest and certify, under penalty of perjury, that the following statement is true: Additional phone number(s) of dependents under your care to be released Add a phone number 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 upload Up to 5 files; 25 MB combined maximum 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 or let our team know that you would like additional information. Clear form Continue