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ROBERT L. EHRLICH, JR., Governor Ch. 374
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(B) AN APPLICATION TO PARTICIPATE IN THE PROGRAM SHALL BE IN THE
FORM REQUIRED BY THE SECRETARY OF STATE AND SHALL CONTAIN:
(1) A STATEMENT THAT:
(I) THE APPLICANT IS A VICTIM OF DOMESTIC VIOLENCE; AND
. (II) THE APPLICANT FEARS FOR THE APPLICANT'S SAFETY OR THE
SAFETY OF THE APPLICANT'S CHILD;
(2) EVIDENCE THAT THE APPLICANT IS A VICTIM OF DOMESTIC
VIOLENCE, INCLUDING:
(I) CERTIFIED LAW ENFORCEMENT, COURT, OR OTHER FEDERAL
OR STATE AGENCY RECORDS OR FILES;
(II) DOCUMENTATION FROM A DOMESTIC VIOLENCE PROGRAM; OR
(III) DOCUMENTATION FROM A RELIGIOUS, MEDICAL, OR OTHER
PROFESSIONAL FROM WHOM THE APPLICANT HAS SOUGHT ASSISTANCE OR
TREATMENT AS A VICTIM OF DOMESTIC VIOLENCE;
(3) A STATEMENT THAT DISCLOSURE OF THE APPLICANT'S ACTUAL
ADDRESS WOULD ENDANGER THE APPLICANT'S SAFETY OR THE SAFETY OF THE
APPLICANT'S CHILD;
(4) A KNOWING AND VOLUNTARY DESIGNATION OF THE SECRETARY OF
STATE AS AGENT FOR PURPOSES OF SERVICE OF PROCESS AND RECEIPT OF
FIRST-CLASS, CERTIFIED, OR REGISTERED MAIL;
(5) THE MAILING ADDRESS AND TELEPHONE NUMBER WHERE THE
APPLICANT MAY BE CONTACTED BY THE SECRETARY OF STATE;
(6) THE ACTUAL ADDRESS THAT THE APPLICANT REQUESTS NOT BE
DISCLOSED BY THE SECRETARY OF STATE BECAUSE IT WOULD INCREASE THE RISK
OF DOMESTIC VIOLENCE;
(7) A STATEMENT AS TO WHETHER THERE IS ANY EXISTING COURT
ORDER OR PENDING COURT ACTION INVOLVING THE APPLICANT AND RELATED TO
DIVORCE PROCEEDINGS, CHILD SUPPORT, CHILD CUSTODY, OR CHILD VISITATION,
AND THE COURT THAT ISSUED THE ORDER OR HAS JURISDICTION OVER THE ACTION;
(8) A SWORN STATEMENT BY THE APPLICANT THAT TO THE BEST OF
THE APPLICANT'S KNOWLEDGE ALL OF THE INFORMATION CONTAINED IN THE
APPLICATION IS TRUE; AND
(9) THE SIGNATURE OF THE APPLICANT AND THE DATE ON WHICH THE
APPLICANT SIGNED THE APPLICATION; AND
(10) A VOLUNTARY RELEASE AND WAIVER OF ALL FUTURE CLAIMS
AGAINST THE STATE FOR ANY CLAIM THAT MAY ARISE FROM PARTICIPATION IN THE
PROGRAM EXCEPT FOR A CLAIM BASED ON GROSS NEGLIGENCE.
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- 2025 -
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