Fillable Safe at Home Application Instructions

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Safe at Home Application Instructions

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Safe at Home
Wisconsin Address Confidentiality Program
Application Instructions
• Complete this application AFTER meeting with a Safe at Home designated Application Assistant to create a safety
plan. If you need information about how to find a designated Application Assistant, please call Safe at Home at 1-
800-446-6564 or email: Safeathome@doj.state.wi.us
• Complete your application as clearly and thoroughly as possible. The more information you provide, the better we
can protect your actual address.
Eligibility Requirements
1. Applicant must be a Wisconsin resident.
2. Applicant must be a victim of an act or threat of abuse, a parent or guardian of a person who is a victim of an
act or threat of abuse, or a resident of a household in which a victim of an act or threat of abuse also resides;
or the applicant must fear for his or her physical safety or for the physical safety of his or her child or ward.
“Abuse” means domestic abuse, child abuse, sexual abuse, stalking, and/or trafficking.
3. The applicant resides or will reside at a location in Wisconsin that is not known by the person who committed
the abuse against, or who threatens the applicant or his or her child or ward.
4. The applicant may not disclose his or her actual residential, work, or school address to the person who
committed the abuse against, or who threatens the applicant or his or her child or ward.
An applicant may be eligible regardless of whether any criminal charges have been brought, whether the applicant
has sought a restraining order, or whether the applicant has reported any act or threat to law enforcement.
Section 1
• Section 1 should be completed by the primary adult applicant. If you are completing the application on behalf of
your child(ren) or ward(s), please put yourself as the primary applicant and list your children or wards at the end of
Section 1.
• All adult applicants should complete their own Safe at Home application, regardless of whether or not they reside
with other adult applicants.
• You may choose to use your Safe at Home assigned address in place of a work or school address.
• All minor children and wards residing in the home of the primary adult applicant should be listed at the end of
Section 1 to ensure that they are properly authorized to use the Safe at Home address to receive mail.
Section 2
• Section 2 requests information about the DOJ designated Application Assistant with whom you worked to create
your safety plan.
• In very limited situations, state or local government agencies or law enforcement may request information about
participants. Safe at Home asks that you provide complete information about the abuser or person you fear so
that we may be diligent in protecting your information from that person.
Section 3
• Section 3 is optional, but providing the information requested in this section will allow Safe at Home staff to provide
additional safety planning resources specifically tailored to your needs.
• If you plan to move shortly after submitting this application, write your new address and the date that it will be
effective on a piece of paper and submit it along with this application.
Safe at Home
Wisconsin Address Confidentiality Program
Application
Section 1: Applicant Information
The primary reason I am enrolling in Safe at Home (check one):
My legal name is:
First
Middle
Last
I may also receive mail under the following name (e.g. maiden name):
First
Middle
Last
My date of birth:
Date
Year
My actual residential address is:
Street Address
Apartment or Unit #
County
City
State
WI
Zip Code
There are other adults that receive mail at this address:
Yes
No
I also plan to use my Safe at Home assigned address in place of a (check all that apply):
School Address
Work Address
I may be contacted at:
Home Telephone #
( )
Mobile Telephone #
( )
Email Address
Is it okay to leave a message concerning your participation in Safe at Home?
Yes
No
My preferred contact method is:
Home Telephone
Mobile Telephone
Email
I am a victim of an act or threat of abuse.
(“Abuse” is defined as child abuse, domestic abuse, sexual abuse, stalking, and trafficking.)
I’m a parent or guardian of a person who is a victim of an act or threat of abuse.
I reside with someone who is a victim of an act or threat of abuse.
I fear for my physical safety or the physical safety of my child or ward.
I am applying on behalf of the following minor children or wards:
Minor Child or Ward’s Legal Name
(First, Middle, Last):
Relationship to Applicant:
Section 2: Additional Information
The Safe at Home designated Application Assistant that assisted me with safety planning is:
Name
Agency
Telephone #
( )
Email Address
Application type (check one):
This is my first time applying to Safe
At Home in Wisconsin.
I previously participated in an
address confidentiality program in
another state.
State: _________________________
I was previously a Safe At Home
participant in Wisconsin and I am re-
applying.
My ID # was: ____________________
I learned about Safe at Home from (check all that apply):
This is the full name of the person(s) I fear:
Name
This person works for a
state or local government
agency, or law
enforcement agency.
Name of the state or local government agency,
or law enforcement agency.
Name
This person works for a
state or local government
agency, or law
enforcement agency.
Name of the state or local government agency,
or law enforcement agency.
Section 3: Optional Information
Do you have motor vehicles that need to be registered in Wisconsin?
Yes
No
Do you have school-age children that will need to enroll in or transfer schools?
Yes
No
Do you plan to register to vote with your Safe at Home assigned address?
Yes
No
Do you own your home or plan to purchase a home in the near future?
Yes
No
A Victim Advocate
Law Enforcement
Court or Judge
Internet
Victim/Witness
Attorney
Family member / Friend
Other: ____________________
Section 4: Applicant Affirmation & Authorization
Signature of Applicant Date
RETURN COMPLETED APPLICATION BY MAIL OR FAX TO:
I solemnly swear or affirm that (check all that apply):
I am a victim, or parent or guardian of a victim, of an act or threat of child abuse, domestic abuse, sexual abuse,
stalking, or trafficking, or a resident of a household in which the victim also resides;
I am a person who fears for his or her physical safety or the physical safety of his or her child or ward;
AND,
I am a resident of Wisconsin;
I reside, or will reside, at a location in Wisconsin that is not known by the person who committed the abuse against
or threatens me or my child/ward;
I will not disclose my actual address (residential street address, school address, or work address) to the person who
committed the abuse against or who threatens me or my child/ward;
I developed a safety plan with a Department of Justice designated Application Assistant;
To the best of my knowledge, all of the information I provided on this application is true and accurate.
I consent to (check all):
Safe at Home notifying me if my participation will expire or if I become disenrolled for failure to update my name or
actual address.
The Department of Justice being designated as my legal agent for service of process and receipt of mail and
authorize the Department of Justice to act on my behalf or in my place for the purpose of receiving mail and service
of process.
I understand that (check all):
Enrollment in Safe at Home is 5 years, unless I voluntarily cancel my enrollment or become disenrolled.
I must notify Safe at Home if and when I change my actual address or legal name and that failure to do so may
result in my disenrollment from Safe at Home.
I may voluntarily cancel my enrollment at any time by submitting written notice to Safe at Home.
If I receive notification from Safe at Home that I was disenrolled, I may update my information and/or reenroll in
Safe at Home within 6 months from the date that Safe at Home provided notice of disenrollment.
Upon unenrollment or disenrollment from Safe at Home, Safe at Home will no longer forward my mail and it will
be returned to sender.
I must personally update my address with all third parties after I unenroll from Safe at Home. I acknowledge that
the US Postal Service cannot accept a change of address form or mail forwarding form from someone ending
their participation in Safe at Home.
Delivery of my mail being delayed due to participation in Safe at Home, including delivery of time sensitive
materials and medications.
Packages, parcels, and periodicals (magazines) and catalogues will not be forwarded to me UNLESS they are
sent by state or local agency or unit of government or are clearly identifiable as containing a pharmaceutical or
medical item.
Safe at Home may notify state or local agencies and units of government that I am enrolled as a participant in
Safe at Home when required by law to do so.
The Department of Justice may disclose my actual address to law enforcement for official purposes or pursuant
to a court order.
Safe at Home
P.O. Box 7035
Madison, WI 53707-7035
608.261.8660
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Safe at Home Application Instructions

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Completed 20 July 2020

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