Section 2. There is hereby established an address confidentiality program to be administered by the secretary under the following application and certification procedures:

(1) Upon recommendation of an application assistant, an adult person, a parent or guardian acting on behalf of a minor, or a guardian acting on behalf of an incapacitated person may apply to the secretary to have an address designated by the secretary serve as the person's address or the address of the minor or incapacitated person.

(2) The secretary shall approve an application only if it is filed with the office of the secretary in the manner established by regulation, and on a form prescribed by the secretary. A completed application shall contain:

(i) the application preparation date, the applicant's signature and the signature and registration number of the application assistant who assisted the applicant in applying to be a program participant;

(ii) a designation of the secretary as agent for purposes of service of process and for receipt of first-class mail;

(iii) the mailing address where the applicant may be contacted by the secretary, or his designee, and the telephone number or numbers where the applicant may be called by the secretary or his designee; and,

(iv) one or more addresses that the applicant requests not be disclosed for the reason that disclosure will jeopardize the applicant's safety or increase the risk of violence to the applicant or members of the applicant's household.

(3) Upon receipt of a properly completed application, the secretary shall certify the applicant as a program participant. An applicant shall be certified for four years following the date of filing unless the certification is withdrawn or invalidated before that date.

(4) The secretary shall forward all first class mail to the appropriate program participants.

(5) A person who knowingly provides false or incorrect information in an application or who knowingly falsely attests that disclosure of the applicant's address threatens the safety of the applicant or the applicant's children or the minor or incapacitated person on whose behalf the application is made, shall be punished by a fine of not more than $500.00 or by imprisonment for not more than six months in a house of correction and by cancellation of program certification.