Pseudonym For Family Violence Survivors Form - Crime Victim Services Division printable pdf download

Pseudonym For Family Violence Survivors Form - Crime Victim Services Division

PSEUDONYM FOR FAMILY VIOLENCE SURVIVORS

All information will be kept confidential

Law Enforcement Agency:

Phone Number:

Case #:

Pseudonym*:

Real Name:

Real Address:

Real Phone # (day):

(evening):

Alternate Contact Name:

Alternate Contact Phone # (day):

(evening):

* This name will be used in all public files to take the place of your real name. Your correct address and phone

number will also be protected. (Texas Code of Criminal Procedure, Chapter 57.)

RELEASE OF INFORMATION

To assist law enforcement with their investigation and obtain further assistance, I give permission for specific

limited release of my real name, address, and phone number. By checking the following, my real information may

be released to these specified agencies.

_____ Local family violence program

_____ District Attorney Crime Victim Coordinator

_____ Law Enforcement Crime Victim Liaison

_____ My medical insurance carrier

_____ Crime Victims’ Compensation

_____ Court ordered restitution office

_____________________________________

___________

Survivor Signature (please use real name)

Date

_____________________________________

___________

Law Enforcement Officer Signature

Badge number

Date

The following program is available to you: _________________________________________________________

(Family Violence Program name and phone number

to be filled in by the officer.)

For more information please contact:

The Office of the Attorney General

Crime Victim Services Division, MC 011-1

Phone: (800) 983-9933

P.O. Box 12548

Fax: (512) 936-1650

Austin, TX 78711-2548

Email:

crimevictims@oag.state.tx.us

Pseudonym For Family Violence Survivors Form - Crime Victim Services Division

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