(a) 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 human trafficking; 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 human trafficking, including:
(i) certified law enforcement, court, or other federal or State agency records or files;
(ii) documentation from a human trafficking prevention or assistance program; or
(iii) documentation from a religious, medical, or other professional from whom the applicant has sought assistance or treatment as a victim of human trafficking;
(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 at which 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 human trafficking or other crimes;
(7) a sworn statement by the applicant that, to the best of the applicant’s knowledge, all the information contained in the application is true;
(8) the signature of the applicant and the date on which the applicant signed the application; and
(9) a voluntary release and waiver of all future claims against the State 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(ii) An applicant shall be a participant for 4 years from the date of filing unless the participation is canceled or withdrawn prior to the end of the 4–year period.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.