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 individual's and child(ren)'s residential address and telephone number; any employer's 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 Worker's Name DRS Worker's Signature _________________________ Date American LegalNet, Inc. www.FormsWorkflow.com