(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.