This government document is issued by Commission on Family Violence for use in Georgia
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https://www.google.com/url?client=internal-element-cse&cx=450907bf5042c4844&q=https://gcfv.georgia.gov/sites/gcfv.georgia.gov/files/related_files/site_page/Victim%2520Contact%2520Request%2520Form%2520Update.pdf&sa=U&ved=2ahUKEwjo3tqAkcCLAxV-TqQEHSFPIDAQFnoECAUQAQ&usg=AOvVaw0HSXaR5G_T6x5j1CQCv5UG