Required: Documentation that verifies an alleged abuser who uses a line on the account has committed, or allegedly committed, a covered act. Accepted documents include:

• Signed affidavit from a medical professional or social worker
• Police report or court record
• Any other official record that documents the covered act
• Self-attestation form (New York residents only)

Optional (dependent lines): A signed and dated affidavit that shows lines you want to separate belong to someone in your care or the care of the survivor you represent

Optional (designated representative): A statement from the representative who helped complete this form on behalf or the survivor