Address Confidentiality Program Online Form - Participation Registration

Primary Participant Information

The person applying to be a program participant can be an adult who is a victim of domestic violence, stalking, sexual offense, kidnapping, and/or human trafficking who fears for his/her safety and has left his/her residence because of such violence, OR, a reproductive health care services provider, employee, volunteer, patient, or immediate family member of a reproductive health care services provider who fears for his/her safety. This category of applicant need not have left his/her residence.

The applicant can also be the parent or legal guardian applying on behalf of a minor (person under 18 years of age) or incapacitated person and must have legal authority to act on the person's behalf. The applicant must choose the appropriate radio button whether s/he is applying on his/her own behalf or on behalf of a minor or incapacitated person and sign the affidavit.

The program participant should include his/her full legal name and date of birth.

If, for safety purposes, you would like your mail forwarded to you under a different name, please contact our office at (855) 350-4595 and we will assist you with this request.

Please list any other names by which you are now or have formerly been known.

Birth Date [MM/DD/YYYY]

Day Phone

Evening Phone

Alt Phone

Email Address
As an alternative method of contact from the ACP, please provide your email address
if you believe it is secure and that your abuser does not have access to it.

Actual Household Address Information

This is the address where the primary participant lives. Applicants must complete this section, including the county name. The address cannot be a Post Office Box. Participation in the ACP Program is limited to New York State residents.

Mailing Address Information

This is the address where the primary participant would like his/her mail delivered. This may be left blank if it is the same as the actual address. The ACP can send mail to a post office box or to an address other than the actual address.

If this address changes, please contact the Address Confidentiality Program for instructions on changing or use the ACP Change/Withdraw Notice . Do not file a change of address with the US Post Office.

Verification Information

The program participant should provide a secret word on the application to create a secure way to make any future changes to the participantâ€™s record. This should prevent unauthorized individuals from making changes to the record. Please keep it in a safe spot.

Program participants should provide a hint to help them remember the secret word. If the program participant cannot remember the secret word when completing a change form, s/he can call the ACP office and a staff member will provide the hint to help remember the word.

Secret Word

Secret Word Hint

Checklist for Program Participant - Please check each item to indicate that you understand

I understand that the ACP is a mail forwarding service only and that my mail will first come to the program's P.O. Box address in Albany before it is forwarded to me. This means it will take longer for me to receive my mail, including legal mail that may contain time sensitive material. I also understand that ACP will only forward first-class mail and legal documents to me and WILL NOT forward magazines, catalogs, packages or junk mail unless clearly identifiable as pharmaceuticals or clearly indicates that it is sent by a government agency.
I understand that it is my responsibility to let state and local government employees know that I want to use the ACP substitute address and that I will need to show them my ACP I.D. card. I also understand that if I give a government agency my actual address, that agency is under no obligation to keep my information confidential.
I understand that my mail may not be forwarded to me if it is sent to a name other than the name on record at ACP.I also understand that if I complete an application form using a name other than my legal name it could result in denial of ACP privileges at certain agencies if a legal name is required to access their services.
I understand that private companies (such as insurance, telephone, utility, etc.) are not obligated to use the ACP substitute address and may require an actual residential street address.
I understand that the ACP is prohibited by law from releasing my actual address to a third party. However, the ACP may release my actual address if ordered by the courts to do so, or if requested by a law enforcement agency for legitimate law enforcement purposes.
I understand that I will be cancelled from the program if I provided false information on my ACP application. I also understand that the ACP will cancel my participation if I change my name or address and do not notify the program within 14 days, or if mail is returned nondeliverable.

Program Participant Affidavit - Please select your affidavit and provide your signature

I affirm that I, as the program participant, am a victim of domestic violence, stalking, sexual offense, kidnapping, and/or human trafficking. I have left my residence because of such violence and I fear for my safety and/or my children's safety. I have legal authority to act on behalf of all minors and/or incapacitated persons included on this application.
I affirm that I am the legal guardian of the applicants indicated on this application and I am acting on behalf of a minor or incapacitated person who is a victim of domestic violence, stalking, sexual offense, kidnapping, and/or human trafficking who has left their residence because of such violence and they fear for their safety. I have legal authority to act on behalf of this minor and/or incapacitated persons included on this application.
I affirm that I, as the program participant, am a reproductive health care services provider, employee, volunteer, patient, or immediate family member of a reproductive health care services provider who fears for his/her safety or the safety of an immediate family member.
I affirm that I am the legal guardian of the applicant(s) indicated on this application and am acting on behalf of a minor who is an immediate family member of a reproductive health care services provider who fears for their safety.

I hereby affirm under penalties of perjury that all information provided on this application is true and correct and that my signature below constitutes my signature. I understand that I will only receive first class, registered and certified mail through this program. The ACP does not forward magazines, packages or junk mail. I understand that moving from the residential address given on this application or changing my mailing address without first notifying the ACP may result in the cancellation of my participation in the ACP. I hereby designate the Secretary of State as my agent for service of process and receipt of mail.

Signature of the Applicant

Helper Agency Information

If an application assistance provider explains the Address Confidentiality Program to the applicant and helps complete the forms, the application should include the name of the agency, the corresponding agency code, the name of the agency contact person and the agency phone number.

If an applicant is applying without the assistance of an agency, completion of this section is not necessary.