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Separate your line from the account holder

The purpose of this form is to help customers who have experienced domestic violence maintain safe connections with their phone line(s)/number(s).

* Required

Domestic Violence Survivor

Self-Attestation

By checking the box below, you certify that the following is true:

I am a survivor of domestic violence.

As a result, I want to move my line(s)/phone number(s) from my current T-Mobile account.

If your request is approved, T-Mobile will release you from your current account without fee or penalty. Please note that upon release the Primary Account Holder will receive automatic notification of a change to the account.

I am a New York resident.

How do you want to separate your T-Mobile account?

Create new account

Join existing account

Provide your name and phone number:

First Name

Last Name

Phone number to be released

Additional phone number(s) of dependents under your care to be released

Configuration - Max number of dependent phone numbers

Please provide the name of the primary account owner:

First Name

Last Name

Upload your additional supporting materials*

Certain laws require you to provide evidence supporting that you are a victim of domestic violence. We treat this documentation confidentially and securely. For more information on our privacy practices, see our Privacy Notice.

Please provide additional supporting material which may include ANY of the following:

Signed affidavit from (1) licensed medical or mental healthcare provider; (2) victim services provider or (3) employee of court acting within the scope of employment
Court Order

Police report of Police statements provided to Magistrate/judges
Charging documents
Protective or restraining orders
Any other official record that documents the domestic violence

Please attach additional information below (Optional for New York Residents):

Attachments (0)

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 , the FCC designated the Lifeline Program, a federal program that lowers the monthly cost of voice or broadband service, to provide 6 months of emergency communications support for eligible qualifying survivors. To see if you qualify please visit National Verifier (NV) - Universal Service Administrative Company (usac.org) and www.lifelinesupport.org . If you would like more information on the Lifeline Program, please let our team know.

Domestic Violence Form

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Signature Form

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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.

National Network to End Domestic Violence

www.nnedv.org for more information.

Find a local domestic violence shelter near you if you need shelter or any other assistance.