Texas Address Confidentiality Program Application
Application Type: NEW REINSTATEMENT RENEWAL
Applicant’s Legal Last Name: First Name: Middle Name:
Address Applicant Wishes to Receive Mail (Residential, Business, School):
City: State: Zip:
County: Date of Birth:
Male
Female
Work Phone (Including Area Code):
Home (Including Area Code):
Cell/Message/Other:
OTHER HOUSEHOLD MEMBER(S) IF PARTICIPATION IS DESIRED
(1) Household Member Last Name: First Name: Middle Name:
Relationship to Applicant: Date of Birth:
Gender: Male Female
(2) Household Member Last Name: First Name: Middle Name:
Relationship to Applicant: Date of Birth:
Gender: Male Female
Applicant has participated in address
confidentiality program before?
Yes No
If yes, what state? Date:
This is for a Victim of: Family Violence Sexual Assault
Stalking
Is there an existing court order or pending court case involving child
support, child custody, or visitation involving the applicant?
Yes No
If yes, the name and address of the legal counsel of record and each parent involved in the court
order or pending court case are as follows:
Advocate’s Last Name:
First Name:
Phone Number:
E-Mail:
Advocate Agency:
Type of Agency:
Advocate’s Signature:
Date:
AFFIRMATION
I fear for my safety because of a threat of immediate or future harm caused by a person who committed, or is
alleged to have committed, family violence, sexual assault, stalking or human trafficking.
I hereby designate the Office of the Attorney General (OAG) as the agent for service of process and receipt of
mail for me and any of the household members listed in this application.
I affirm that the information provided in this application for the Address Confidentiality Program and
any additional information that I provide is true and correct. I understand that the OAG or any agent
or representative of the OAG has the right to verify the information provided. I agree that if false,
misleading or intentionally incomplete information is provided, my application will be denied.
Signature of Applicant OR Parent/Guardian:
Date:
POST OFFICE BOX 12199 AUSTIN, TEXAS 78711-2199 TEL 1-888-832-2322 HTTP://WWW.TEXASATTORNEYGENERAL.GOV/VICTIMS/ACP.SHTML
Gender:
Human Trafficking
