(1) The department shall provide an application form to an applicant who seeks to participate in the program under this part. (2) The department may not charge an applicant or program participant for an application or participation fee to apply for, or participate in, the program. (3) The application shall include: (a) the applicant's name; (b) a mailing address, a phone number, and an email address where the applicant may be contacted by the department; (c) an indication regarding whether the assailant is employed by a state or local government entity, and if applicable, the name of the state or local government entity; (d) a statement that the applicant understands and consents to: (i) remain enrolled in the program for four years, unless the applicant's participation in the program is cancelled under Section 75E-11-316; (ii) while the applicant is enrolled in the program, notify the department when the applicant changes the applicant's actual address or legal name; (iii) develop a safety plan with a program assistant; (iv) authorize the department to notify a state or local government entity that the applicant is a program participant; (v) submit written notice to the department if the applicant chooses to cancel the applicant's participation in the program; (vi) register to vote in person at the office of the clerk in the county where the applicant's actual address is located; and (vii) certify that the department is the applicant's designated agent for service of process for personal service; (e) evidence that the applicant, or a minor or an incapacitated individual residing with the applicant, is a victim, including: (i) a law enforcement, court, or other state, local, or federal government agency record; or (ii) a document from: (A) a domestic violence program, facility, or shelter; (B) a sexual assault program; or (C) a religious, medical, or other professional from whom the applicant, or the minor or the incapacitated individual residing with the applicant, sought assistance in dealing with alleged abuse, domestic violence, stalking, or a sexual offense; (f) a statement from the applicant that a disclosure of the applicant's actual address would endanger the applicant, or a minor or an incapacitated individual residing with the applicant; (g) a statement by the applicant that the applicant: (i) resides at a residential address that is not known by the assailant; (ii) has relocated to a different residential address in the past 90 days that is not known by the assailant; or (iii) will relocate to a different residential address in the state within 90 days that is not known by the assailant; (h) the actual address that: (i) the applicant requests that the department not disclose; and (ii) is at risk of discovery by the assailant or potential assailant; (i) a statement by the applicant disclosing: (i) the existence of a court order or action involving the applicant, or a minor or an incapacitated individual residing with the applicant, related to a divorce proceeding, a child support order or judgment, or the allocation of custody or parent-time; and (ii) the court that issued the order or has jurisdiction over the action; (j) the name of any other individual who resides with the applicant who needs to be a program participant to ensure the safety of the applicant, or a minor or an incapacitated individual residing with the applicant; (k) a statement by the applicant that: (i) the applicant, or a minor or an incapacitated individual residing at the same address as the applicant, will benefit from participation in the program; (ii) if the applicant intends to vote, the applicant will register to vote at the office of the clerk in the county in which the applicant actually resides; and (iii) the applicant does not have a current obligation to register as a sex offender, kidnap offender, or child abuse offender under Title 53, Chapter 29, Sex, Kidnap, and Child Abuse Offender Registry; (l) a statement by the applicant, under penalty of perjury, that the information contained in the application is true; (m) a statement that: (i) if the applicant intends to use the assigned address for any correspondence with the State Tax Commission, the applicant must provide the State Tax Commission with the applicant's social security number, federal employee identification number, and any other identification number related to a tax, fee, charge, or license administered by the State Tax Commission; and (ii) if the applicant intends to use the assigned address for correspondence to a state or local government entity for the purpose of titling or registering a motor vehicle or a watercraft that is owned or leased by the applicant, the applicant shall provide to the state or local government entity for each motor vehicle or watercraft: (A) the motor vehicle or hull identification number; (B) the license plate or registration number for the motor vehicle or the watercraft; and (C) the physical address where each motor vehicle or watercraft is stored; and (n) a statement that any assistance or counseling provided by a program assistant as part of the program does not constitute legal advice or legal services to the applicant. Renumbered and Amended by Chapter 291, 2026 General Session
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