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Family Violence Indicator - Pennsylvania

Family Violence Indicator Form. This is a Pennsylvania form and can be used in Civil Westmoreland Local County .
 Fillable pdf Last Modified 3/12/2008
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FAMILY VIOLENCE INDICATOR I understand the Family Violence Indicator (FVI) is being entered on my file in the Pennsylvania Child Support Enforcement System because of safety concerns. I understand the FVI will result in the following: Correspondence sent by the Domestic Relations Section to one individual will not include the location of the other individual or child. This includes: the individuals and child(ren)s residential address and telephone number; any employers address, telephone number and name; the identity and location of medical providers (in connection with insurance claim information); and the county assistance office address. The FVI will be transmitted to the Federal Parent Locator database, which will protect confidential information. However, if the need for the information is documented and approved by the court through the FVI override process, then such information will be released. PACSES Number _______________________ Name (Printed) _________________________________ Signature ____ __________________________________ Date _________________ DRS Workers Name ____________________________ DRS Workers Signature _________________________ Date _________________ <<<<<<<<<********>>>>>>>>>>>>> 2 AUTHORIZATION TO REMOVE FAMILY VIOLENCE INDICATOR Name of DRS client: ________ _____________________________________________ PACSES Member Identification Number: _____________________________________ I, __________________________________, request the removal of the family violence indicator, or "V" code, from my child support case for ___________________________ (enter child(ren)s names in space provided). I have chosen the following option by marking an "X" on the provided line to the left. _____ I request that the family violence indicator, or "V" code, be removed from my case. I understand that removing this indicator will permit information, that may reveal employer data and the whereabouts and address of myself and my children), to be released to the other party in the support action. I further understand that this affects ALL of my support cases. _____ I request that the family violence indicator, the "V" code, be changed to a confidential indicator, or "C" code, on my case. By doing so, I understand that my child support case will read "confidential only" and my address will not be shared with the other party to the support action. Furthermore, I understand that support enforcement efforts will continue, for any reason unrelated to domestic violence, while my address is listed as confidential. _____ I request that the family violence indicator, the "V" code, be changed to a "N" code on my case. I understand that this change means that my address will not be kept confidential, and that I am confirming that domestic violence is no longer a concern. I also understand that the change of this indicator means my case is no longer confidential and information that may reveal employer data and the whereabouts and address of myself and my child(ren), will be released to the other party in the support action. I further understand that this affects ALL of my support cases. _____________________________________ Client Signature/Date _____________________________________ Client Name (Printed) Witness Signature/Date _____________________________________ Witness Name and Title (Printed)
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