ACP APPLICATION

Select an Option Myself Minor Ward

Select an Option JR II III SR

Select an Option Male Female Non-Binary Prefer not to disclose

Select an Option Home Mobile Business

Select an Option Home Mobile Business

Select an Option Email Phone Alternate Phone

Select an Option Yes No

Select an Option Yes No

Are there any other adults that will be seeking to keep this address confidential? If so, provide their first name, last name, email address and relationship to applicant in the text box below. (Note: All adult applicants must complete and sign separate applications).

Actual physical residence address that applicant wants to keep confidential. (Note: actual address location is required for participation):

Select an Option Yes No

Select an Option Yes No

Select an Option Yes No

Select an Option Yes No

Select an Option Yes No

Select an Option Yes No

A notarized statement must be signed and submitted with this application. Please see the ACP instruction page for valid notarization options. The ACP Notarized Statement can be downloaded from the ACP website (mi.gov/agacp):

Select an Option Yes No

Select an Option Yes No

Select an Option Yes No

If you wish to cancel your voter registration, refer to the ACP handbook for cancellation steps. If you wish to register to vote and do not have a Michigan driver's license, state ID or Social Security number, complete an ACP Voter Registration form and submit it to the Address Confidentiality Program.

1

I voluntarily designate DTMB as my agent for the purpose of receiving mail and service of process. I understand that DTMB will forward mail and any documents to my confidential address. Participating in the ACP means it will take longer for me to receive my mail. I further understand that DTMB will not forward 3rd class mail, junk mail or packages to my confidential address.

2

I understand that ACP will assign me a designated address that I can provide to any state or local governmental entity in the State of Michigan whenever an address is required, and that these governmental entities must use the designated address I provide. I understand that private non-governmental entities are not required by law to use the designated address; however, I am entitled to provide the designated address to them and to ask that they use it.

3

I understand that enrollment is for 4 years, and I may submit a renewal application to renew my participation in the program.

4

I understand my participation in the program can be cancelled with proper notice from ACP if (a) I am unreachable for more than 60 days at the address I provided ACP, (b) I make a false statement on my application, (c) I fail to renew my application during the initial certification period, (d) I request cancellation, or (e) I fail to file a continuance application before the minor in my household turns 19 years of age.

5

I understand the ACP can disclose my actual confidential address to a department of the state, law enforcement agency, or local unit of government if that entity requests the address for a legitimate governmental purpose and has been unable to contact me at my designated address. ACP must promptly notify me of any such request.

6

I understand that knowingly making a false statement in this application is a misdemeanor punishable by up to 93 days’ imprisonment or a maximum fine of $500, or both.

7

I agree and acknowledge that some aspects of how the ACP is managed or administered may change over time and that I will need to comply with those changes in order to remain in the program.

8

I agree and acknowledge that ACP may contact me via my preferred method of communication.

9

By submitting this application I do not waive any legally recognized privilege or confidentiality protecting any communications that may have with the agency or representative whose name appears as the application assistant or victim advocate or with any other person or entity.

10

I am not listed on nor required to register on the Michigan Sex Offender Registry.

11

I agree and acknowledge that the ACP will provide my driver's license or state ID number and that of my minor/ward listed on my application to the Secretary of State (SOS) for purposes of processing my corrected driver's license or state ID card and/or corrected or new voter registration card with the designated address. I also agree that the SOS will provide my driver's license or state ID number, or that of my minor/ward, to the ACP to update my ACP record.

Select an Option Yes

I understand that by typing my name and clicking the “Submit” button below, that it constitutes my legal signature on the Address Confidentiality Program (ACP) application.