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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.

Survivor's Name(Required)
Survivor’s Designated Representative*
*If someone is assisting with or requesting the line separation on behalf of the survivor, please provide the following information:
The Designated Representative's Name
Abuser's Name(Required)
Under SCA rules, in order for CellularOne to process this line separation request, you must provide documentation that verifies the alleged abuser has committed or allegedly committed a covered act against the survivor or an individual in the survivor’s care. Acceptable documentation includes either (1) a copy of a signed affidavit from a licensed medical or mental health care provider, licensed social worker, victim services provider, or an employee of a court acting within the scope of that person’s employment; (2) a copy of a signed affidavit from a licensed military medical or mental health care provider or licensed military victim services provider; (3) a copy of a police report or statements provided by police to a magistrate or a judge (4) charging documents; (5) protective orders; (6) restraining orders, or military protective orders; or (7) a copy of any other official record that documents the covered act.
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    Cellular One may need to contact you or your designated representative to confirm the line separation or notify you if we are unable to complete the requested line separation.
    Please indicate how we may contact you concerning this line separation request.
    We will only contact you by the means identified here. We will not use this information for marketing, advertising, or any reason not directly related to this line separation request.
    We will only contact you by the means identified here. We will not use this information for marketing, advertising, or any reason not directly related to this line separation request.
    Please create a pin or password that you will remember so that our agent can confirm your identity when contacting you. If you are using a designated representative, please make sure to share this pin or password with them.

    Please indicate the type of line separation you are requesting.

    Survivors may separate (1) their line(s) and the line(s) of any individual in their care from the shared mobile service contract or (2) the line(s) of the abuser from the shared mobile service contract. You must identify which phone line should be requested by providing the phone number associated with the relevant line. We will attempt to process the request in the manner you select.
    Survivor's Phone Line
    Note:
    If there is a device (i.e., phone, tablet) associated with this one line, please indicate whether you will assume financial responsibility for this device.
    Dependent's Phone Line
    * To request the separation of the phone line(s) of individuals under the survivor’s care, you must provide a signed affidavit (i.e., a statement of facts setting forth that the relevant individual is in the care of the survivor and is the user of the specific line). The affidavit must be dated near in time to when it is submitted to us.
    If there is a device (i.e., phone, tablet) associated with this one line, please indicate whether you will assume financial responsibility for this device.
    Abuser's Phone Line
    If you wish to separate the abuser’s line, you must state that the abuser is the user of the relevant line.

    Authentication Process

    To protect the security of our customers, we must attempt to authenticate that the survivor requesting the line separation is the user of the specific line(s). To authenticate the user of the specific line, we may (1) Ask for the account number, pin, password, address, or ask if you are an authorized user and to provide ID. It is NOT REQUIRED for you to know any of that information to proceed. (2) The specialized CARE agent may place a call to the number that is being asked to be separated to confirm it is in fact the survivor’s line. If we are unable to authenticate the user or have a reasonable belief that the request may be fraudulent, we may deny the line separation request(s).

    Financial Support For Emergency Communications for Qualifying Survivors

    The federal Lifeline Program (“Lifeline”) is a source of support for emergency communications for survivors experiencing financial hardship. Financial Hardship. Under SCA rule, a survivor is suffering from “financial hardship, (1) if the survivor, one or more of the consumer’s dependents, or the survivor’s household is receiving benefits from one of the following federal assistance programs: Medicaid; Supplemental Nutrition Assistance Program; Supplemental Security Income; Federal Public Housing Assistance; or Veterans and Survivors Pension Benefit; (2) the household’s income is at or below 200% of the Federal Poverty Guidelines for a household of that size; (3) at least one member of the household has applied for and been approved to receive benefits under the free and reduced price lunch program under the Richard B. Russell National School Lunch Act or the school breakfast program under section 4 of the Child Nutrition Act of 1966, (4) at least one member of the household is enrolled in a school or school district that participates in the Community Eligibility Provision; (5) at least one member of the household has received a Federal Pell Grant under section 401 of the Higher Education Act of 1965 in the current award year, if such award is verifiable through the National Verifier or National Lifeline Accountability Database or “the participating provider verifies eligibility under § 54.1806(a)(2);” or (6) at least one member of the household receives assistance through the special supplemental nutritional program for women, infants and children “established by section 17 of the Child Nutrition Act of 1996.”

    With the Lifeline program, eligible low-income customers can receive a discount on their monthly service from mobile telecommunications.

    Only one Lifeline discount is allowed per household and a household cannot receive Lifeline benefits from multiple providers. Unless you can qualify to participate in Lifeline under the programs’ general eligibility requirements, qualified survivors may receive the benefit for up to six months.

    Households may qualify for Lifeline based on income

    If income is 135% or less than the federal poverty guidelines. Visit lifelinesupport.org/do-i-qualify/#income for guidelines.

    Households may qualify for Lifeline based on participation in a qualifying federal assistance program

    Programs such as (1) Supplemental Nutrition Assistance Program (SNAP), formerly known as Food Stamps (2) Medicaid (3) Supplemental Security Income (SSI) (4) Federal Public Housing Assistance (FPHA) (5) Veterans Pension and Survivors Benefit (6) Tribal Programs (and live on federally recognized Tribal lands) are examples of qualifying programs.
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