Line Separation Form

Please enable JavaScript in your browser to complete this form.

If you need any help completing this form please contact USAFV by calling 907-581-1500 or 1-800-478-7238 anytime, or by texting 907-359-1500 from 8am to 11pm daily.

Survivor's Name

This is the name of the person who is requesting relief from the abuser pursuant to section 345 of the Communications Act of 1934

Other individuals in the care of the survivor*

We will need affidavits completed for each survivor listed in the care of to complete line transfers.

Contact phone Numbers (We WILL try to call you on this number)

Enter any phone numbers we can safely contact you with

YOUR Contact Email Address

Confirm Email

(Optional) An email address where we can contact you.

Contact Preference

Primary Phone
Email

If any of these are better than any others, we will use them first when trying to reach you

Separating Phone Number(s)

List your phone number and any additional phone numbers that you need to separate for dependents. We will not contact these numbers unless they are listed in the “Contact Phone Numbers” field above

Abuser's Name

Abuser's Phone Number(s)

We will NOT CONTACT these numbers.

Are you the primary account holder

No
Yes
I don’t know

Documentation Upload

For us to process line separation requests, you must provide documentation of the abuse. Acceptable documents include copies of signed affidavits of licensed medical or mental health care provider, licensed military medical or mental health care provider, licensed social worker, victims services provider, licensed military victim services provider or, an employee of a court acting within the scope of that person’s employment,

You may also use a copy of a police report, statements provided by police to a magistrate or a judge, charging documents, protective or restraining orders, military protective orders, or any other official record that documents the covered act.

Click or drag files to this area to upload. You can upload up to 5 files.

We accept PDF, PNG, JPG, GIF and BMP. If you need to submit a different format, please make a note in special instructions and we will reach out to you to add the format. If you need help obtaining this you may contact Unalaskans Against Sexual Assault & Family Violence https://www.usafvshelter.org/ for assistance.

Special Instructions

If there are any hours that we should avoid contacting you, specific people we can talk to other than you, or any other detail that will help us reach you if we have questions or to assist with moving your phone number to you, please let us know.

Confidentiality and What to Expect Next

We will contact you as soon as we receive this to confirm details of this form. This will generally be within 24 hours. If you have not received a response within 24 hours, please resubmit this form, taking care that we have a contact phone number, or a contact email. Please check spam and blocking filters to make sure we are not having our calls blocked. If for whatever reason this is not working, please call our support center at +1 (907) 581-7825 and ask for someone who can complete a separation request. The person answering the call will direct you to someone who can assist you with this.