The Secretary of the State shall certify an applicant or the person on whose behalf an application is made as a program participant if the application is filed in the manner and on the application form prescribed by the Secretary of the State and includes:
(1) A statement made under penalty of false statement, as provided in section 53a-157b, that (A) the applicant or the person on whose behalf the application is made is a victim of family violence, injury or risk of injury to a minor, sexual assault or stalking, and (B) the applicant fears for the applicant's safety, for the safety of the applicant's children, for the safety of the person on whose behalf the application is made, or for the safety of the children of the person on whose behalf the application is made;
(2) Documentation supporting the statement made pursuant to subdivision (1) of this section;
(3) A designation of the Secretary of the State as the agent of the applicant or the person on whose behalf the application is made for service of process and for receipt of first class mail;
(4) The residential address in this state, the work and school addresses in this state, if any, and the phone number or numbers, if available, that are to remain confidential, but which may be used by the Secretary of the State or authorized personnel to contact the applicant or the person on whose behalf the application is made; and
(5) The application preparation date, the applicant's signature and the signature of the application assistant who assisted the applicant in completing the application.
(P.A. 03-200, S. 4.)
History: P.A. 03-200 effective January 1, 2004.
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