Safe Connections Act | Astound Forms

Survivor's First Name
Survivor's Last Name
You are a "Survivor" if you are an adult experiencing domestic abuse OR if you are an adult who cares for someone experiencing domestic abuse (even if you are not personally experiencing domestic abuse) (a "Caregiver" or “Designated Representative”).
If you are a Caregiver or Designated Representative, only provide your name, not the name(s) of individual(s) in your care.
Are you seeking an Astound mobile line separation as a Caregiver or Designated Representative? (Optional)
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A "Caregiver" or "Designated Representative" is an individual who prepares and submits a line separation request on behalf of a Survivor, who is at least 18 years old and “cares for” someone else against whom domestic violence has been committed or allegedly committed. Persons in care of a Caregiver may be: (1) individuals in the same household; (2) parents, guardians, or minor children even if they live at a different address; (3) individuals being cared for by court order or power of attorney; or (4) parents, guardians, or non-minor children who are financially or physically dependent.
By typing your name below, you are signing this form electronically and agree that you are a Caregiver of the user of the Astound mobile telephone line(s) identified below as “Survivor User” and such line(s) is / are in use by the person in your care. You further agree that, by typing your name and date below, you are placing your signature on this document, and that your signature below is as valid as if you signed the document in writing.
Date
Caregiver / Designated Representative Name
Survivor’s, Caregiver’s, or Designated Representative’s Email Address
Whose Email is this?
Survivor Caregiver Designated Representative
Survivor’s, Caregiver’s, or Designated Representative’s Mobile Phone Number
Whose mobile number is this?
Survivor Caregiver Designated Representative
You will be contacted with this information to confirm the request or if we are unable to complete the request.

THIS CONTACT SHOULD BE DIFFERENT FROM YOUR EXISTING ASTOUND MOBILE TELEPHONE NUMBER.
Survivor’s, Caregiver's, or Designated Representative’s Preferred Language for Communications about this Request
English Spanish

Except in New York State, please attach the following supporting documentation:
- A signed affidavit from either: a licensed medical or mental health care provider, a licensed social worker, a victim services provider, or a court employee acting within the scope of employment.
- A police report or a document showing statements provided by the police to a court.
- A charging document, a protective order, or a restraining order.
- Any other official record that documents the abuse.
Please upload your documentation
Drop files here or

Accepted file types: jpeg, jpg, gif, png, pdf, doc, docx, txt, Max. file size: 10 MB, Max. files: 4.

By submitting this form to Astound, you are seeking a line separation request under federal law, and agree that the information contained on this form is true and accurate to the best of your knowledge.
Contact me: I need assistance filling out this form.
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Contact me: I don’t need help with the form but I would like to speak with someone.
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Step 1 of 4 - Survivor Information