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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.
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
Email
Phone number to be released
Additional phone number(s) of dependents under your care to be released
Add a phone number
X
Select an optionParentChild Or DependentOther
Configuration - Max number of dependent phone numbers
__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](https://www.t-mobile.com/privacy-center/privacy-notices/t-mobile-privacy-notice?INTNAV=fNav%3APrivacyNotice).
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)
Select a file to uploadMaximum file size allowed is 25MB.
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.
Domestic Violence Form
# __Something went wrong. Please try again.__
# Signature Form
Signature Step
Loading document...
# 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](https://www.hotline.org).__
__National Network to End Domestic Violence__
__[www.nnedv.org](https://www.nnedv.org) for more information.__
__Find a local [domestic violence shelter near you](https://www.domesticshelters.org/help#?page=1) if you need shelter or any other assistance.__
# 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:
- SSN
- Driver’s license number
- 6-8 digit account PIN
__Additional resources:__
__National Domestic Violence Hotline__
__1-800-799-SAFE (7233) or visit their website at [www.thehotline.org](https://www.thehotline.org).__
__National Network to End Domestic Violence__
__[www.nnedv.org](https://www.nnedv.org) for more information.__
__Find a local [domestic violence shelter near you](https://www.domesticshelters.org/help#?page=1) if you need shelter or any other assistance.__
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