Line Separation Request

The Safe Connections Act (“SCA”) helps ensure that survivors of domestic violence, human trafficking, and other related crimes and abuse can separate their mobile phone line(s) from a service contract shared with an abuser. Under the SCA rules, a “survivor” is an individual who is at least 18 years old against whom a covered act (i.e., domestic violence, dating violence, sexual assault, stalking, sex trafficking, and other similar acts as has been committed or allegedly committed); or someone who cares for another individual against whom a covered act has been committed or allegedly committed. An abuser is an individual who has committed or allegedly committed a covered act against a survivor or an individual in the care of a survivor who seeks relief pursuant to SCA. Completion of this form indicates that a survivor is seeking relief pursuant to section 345 of the Communications Act and related rules of the Federal Communications Commission (“FCC”). Cellular One can only process valid line separation requests and is therefore required to obtain certain information, including documentation that verifies that an “abuser” has committed or allegedly committed a covered act against the survivor or an individual in the survivor’s care. Cellular One will treat the information provided on this form and any other information related to this line separation request as confidential. Accordingly, Cellular One will only disclose or permit access to information related to this line separation request: pursuant to a valid court order; to the survivor submitting the line separation request; to anyone that the survivor specifically designates; to those third parties necessary to effectuate the request (i.e., vendors, contractors, and agents); or, to the extent necessary, to the FCC or the Universal Service Administrative Company for processing of emergency communications support through the Lifeline program. Beginning on the date on which Cellular One transfers billing responsibilities for and use of phone number(s) to a survivor following pursuant to this line separation request, the survivor will assume financial responsibility, including for monthly service costs, for the transferred telephone number(s), unless ordered otherwise by a court. On that day, the survivor will not assume financial responsibility for any mobile device(s) associated with the separated line(s), unless you purchased the mobile device(s); affirmatively elect to maintain possession of the mobile device(s); or unless otherwise ordered by a court.