A. On the recommendation of an application assistant, an individual may apply to the secretary of state to participate in the address confidentiality program. The following individuals may apply to the secretary of state to have an address designated by the secretary of state to serve as the substitute address of the individual and any individuals identified pursuant to subsection C, paragraph 10 of this section:

1. An adult individual.

2. A parent or guardian acting on behalf of a minor if the minor resides with the individual.

3. A guardian acting on behalf of an incapacitated individual.

B. 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 serves as the recommendation by the application assistant that the applicant have an address designated by the secretary of state 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 subsection A, paragraph 2 or 3 of this section is 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.

C. The application shall be on a form prescribed by the secretary of state and shall contain all of the following:

1. The applicant’s name.

2. A statement by the applicant that the applicant is a victim of domestic violence, a sexual offense or stalking and that the applicant fears for the applicant’s safety.

3. Evidence that the applicant is a victim of domestic violence, a sexual offense or stalking. This evidence shall include at least one of the following:

(a) Law enforcement, court or other state or local government entity or federal agency records or files.

(b) Documentation from a domestic violence program or facility, including a battered women’s shelter or safe house, if the applicant is alleged to be a victim of domestic violence.

(c) Documentation from a sexual assault program if the applicant is alleged to be a victim of a sexual offense.

(d) Documentation from a religious, medical or other professional from whom the applicant has sought assistance in dealing with the alleged domestic violence, sexual offense or stalking.

4. A statement by the applicant that disclosure of the applicant’s actual address would endanger the applicant’s safety.

5. A statement by the applicant that the applicant has confidentially relocated in the past ninety days or will confidentially relocate in this state.

6. A designation of the secretary of state as an agent for the applicant for purposes of receiving service of process and first class, election, registered and certified mail.

7. The mailing address and telephone number where the applicant can be contacted by the secretary of state.

8. The actual address that the applicant requests not to be disclosed by the secretary of state and that directly relates to the increased risk of domestic violence, a sexual offense or stalking.

9. A statement as to whether there is any existing court order or court action involving the applicant or an individual identified pursuant to paragraph 10 of this subsection related to dissolution of marriage proceedings, child support or the allocation of parental responsibilities or parenting time. The statement shall include the name of the court that issued the order or that has jurisdiction over the action, the case number and the judge assigned to the case.

10. The name of any person who resides with the applicant and 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 the person to be a program participant.

11. 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.

D. On determining that an application is properly completed, the secretary of state shall certify the applicant and any individual who is identified pursuant to subsection C, paragraph 10 of this section as program participants. On certification, the secretary of state shall issue to the program participant an address confidentiality program authorization card, which shall include the program participant’s substitute address. The card remains valid while the program participant remains certified under the program.

E. Applicants and individuals identified pursuant to subsection C, paragraph 10 of this section are certified for five years following the date of filing unless the certification is withdrawn or canceled before the end of the five-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 secretary of state at least thirty days before the expiration of the current certification. The renewal application shall be dated, signed and verified by the applicant. The renewal application shall contain:

1. Any statement or information that is required by subsection C of this section and that has changed from the original application or a prior renewal application.

2. 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.