(a)    Any of the following individuals may apply to participate in the Program:

(1)    an individual acting on the individual’s own behalf;

(2)    a parent or guardian acting on behalf of a minor who resides with the parent or guardian; or

(3)    a guardian acting on behalf of a disabled person.

(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;

(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.

(c)    (1)    (i)    On the filing of a properly completed application and release, the Secretary of State shall:

1.    review the application and release; and

2.    if the application and release are properly completed and accurate, designate the applicant as a Program participant.

(ii)    An applicant shall be a participant for 4 years from the date of filing unless the participation is canceled or withdrawn prior to the end of the 4-year period.

(2)    A Program participant may withdraw from participation by filing a signed, notarized request for withdrawal with the Secretary of State.