(1) On and after July 1, 2008, upon the recommendation of an application assistant, an individual may apply to the executive director or his or her designee to participate in the address confidentiality program. The following individuals may apply to the executive director or his or her designee to have an address designated by the executive director or his or her designee to serve as the substitute address of the individual and any individuals designated in paragraph (j) of subsection (3) of this section: (a) An adult individual; (b) A parent or guardian acting on behalf of a minor when the minor resides with the individual; or (c) A guardian acting on behalf of an incapacitated individual. (2) An application assistant shall assist the individual in the preparation of the application. The application shall be dated, signed, and verified by the applicant and shall be signed and dated by the application assistant who assisted in the preparation of the application. The signature of the application assistant shall serve as the recommendation by such person that the applicant have an address designated by the executive director or his or her designee to serve as the substitute address of the applicant. A minor or incapacitated individual on whose behalf a parent or guardian completes an application pursuant to the authority set forth in paragraph (b) or (c) of subsection (1) of this section shall be considered the applicant, but any statements that are required to be made by the applicant shall be made by the parent or guardian acting on behalf of the minor or incapacitated individual. (3) The application must be on a form prescribed by the executive director or the executive director's designee and must contain the following: (a) The applicant's name; (b) A statement by the applicant that the applicant is a victim of domestic violence, a sexual offense, human trafficking, or stalking and that the applicant fears for the applicant's safety, if applicable; (c) Evidence that the applicant is a victim of domestic violence, a sexual offense, human trafficking, or stalking, if applicable. This evidence may include any of the following: (I) Law enforcement, court, or other state or local government agency or federal agency records or files; (II) Documentation from a domestic violence program or facility, including but not limited to a battered women's shelter or safe house, if the applicant is alleged to be a victim of domestic violence; (III) Documentation from a sexual assault program if the applicant is alleged to be a victim of a sexual offense; or (IV) Documentation from a religious, medical, or other professional from whom the applicant has sought assistance in dealing with the alleged domestic violence, sexual offense, human trafficking, or stalking. (d) A statement by the applicant that disclosure of the applicant's actual address would endanger the applicant's safety; (e) A statement by the applicant that the applicant has confidentially relocated in the past ninety days or will confidentially relocate in the state; (f) A designation of the executive director or his or her designee as an agent for the applicant for purposes of receiving certain mail; (g) The mailing address and telephone number where the applicant can be contacted by the executive director or his or her designee; (h) The actual address that the applicant requests not to be disclosed by the executive director or the executive director's designee that directly relates to the increased risk of domestic violence, a sexual offense, human trafficking, or stalking, or increased risk of actual or threatened violence, stalking, human trafficking, or other social harms due to the provision of a legally protected health-care activity, as defined in section 12-30-121 (1)(d); (i) A statement as to whether there is any existing court order or court action involving the applicant or an individual identified in paragraph (j) of this subsection (3) related to dissolution of marriage proceedings, child support, or the allocation of parental responsibilities or parenting time and the court that issued the order or has jurisdiction over the action; (j) The name of any person who resides with the applicant who also needs to be a program participant in order to ensure the safety of the applicant and, if the person named in the application is eighteen years of age or older, the consent of such person to be a program participant; (k) A statement by the applicant, under penalty of perjury, that to the best of the applicant's knowledge, the information contained in the application is true; and (l) A statement by the applicant, under penalty of perjury, that the applicant is a protected health-care worker or provides, refers, or assists patients in accessing a legally protected health-care activity, as defined in section 12-30-121 (1)(d), if applicable. (4) Upon determining that an application has been properly completed, the executive director or his or her designee shall certify the applicant and any individual who is identified in paragraph (j) of subsection (3) of this section as a program participant. Upon certification, the executive director or his or her designee shall issue to the participant an address confidentiality program authorization card, which shall include the participant's substitute address. The card shall remain valid for so long as the participant remains certified under the program. (5) Applicants and individuals identified in paragraph (j) of subsection (3) of this section shall be certified for four years following the date of filing unless the certification is withdrawn or canceled prior to the end of the four-year period. A program participant may withdraw the certification by filing a request for withdrawal acknowledged before a notary public. A certification may be renewed by filing a renewal application with the executive director or his or her designee at least thirty days prior to expiration of the current certification. The renewal application shall be dated, signed, and verified by the applicant. The renewal application shall contain: (a) Any statement or information that is required by subsection (3) of this section that has changed from the original application or a prior renewal application; and (b) A statement by the applicant, under penalty of perjury, that to the best of the applicant's knowledge, the information contained in the renewal application and a prior application is true.
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