Forms and Helpful Information

Below you can find copies of all Safe at Home forms and informational documents. These forms may be used to apply for the program, to update your contact information with the program, to request assistance verifying your eligibility for public benefits enrollment, or for other purposes. The informational handouts will give you more information about eligibility and application requirements, how to make the most of your program participation, how to interact with state and local government agencies, and more.

Forms

Initial Application for Program Participation - ** Note: The Safe at Home Program will begin to accept applications for program participation on March 1, 2019.** Use this form to apply for the Safe at Home Program. Remember that applications must be completed fully, signed by a Certified Application Assistant, and properly notarized. All supporting documentation must also be submitted with the application in order for processing to be completed. If you fail to complete the application or attach the necessary documentation, the processing of your application will be delayed and may be denied. 

Notice of Change - Use this form to let the Safe at Home Program know about any changes in your contact information, your household composition, and more. If you have any questions about this form, please contact the Safe at Home program directly for assistance. Remember that any changes to your contact information or your application information should be reported to the Safe at Home Program within 30 days from the date the change occurred. 

Notice of Name Change - Use this form to let the Safe at Home Program know that you have legally changed your name. Be sure to attach documentation of the change to your submitted form. Remember that a legal change of your name must be reported to the Safe at Home Program within 10 days of the change. 

Petition for Review - Use this form to request a contested case hearing. Participants may request a contested case hearing if they have been notified that their program participation is to be terminated, with limited exceptions, or when they have been notified that their confidential information has been requested by an administrative agency and the Secretary of State has determined that some or all of their information should be disclosed. If you think that you may want to request a contested case hearing, please contact the Safe at Home Program directly to discuss your concerns. 

Eligibility Verification Request - Use this form to request that the Secretary of State verify your eligibility, and the eligibility of your children, for enrollment in public benefits programs or public schools. Participants should fill in their information and take this form to the public benefits agency or public school to be completed by a case manager or registrar. The form should then be submitted directly to the Safe at Home Program for verification and certification. Participants must ensure that their residential address is up to date and that the Safe at Home Program has fully verified their residential address prior to submitting the form. 

Release of School Records - Use this form to request that the Safe at Home Program facilitate the transfer of records from one public school to another. Safe at Home is also happy to facilitate the transfer of records to or from a private school to another school, public or private. 

Renewal Application - This form should be used only by current program participants to renew their program participation. 

Law Enforcement Request for Disclosure - This form is intended for use only by authorized law enforcement officials to request disclosure of information pertaining to a program participant. If you have questions regarding this form, please contact the Safe at Home Program directly. 

Administrative Request for Disclosure - This form is intended for use only by authorized administrative agency officials at either the state or local level. If you have questions regarding this form, please contact the Safe at Home Program directly. 

Withdrawal Form - This form should be submitted only by program participants who no longer wish to participate in the Safe at Home Program. Remember that your withdrawal request must be properly signed and notarized in order to be processed. 

Certified Application Assistant Application - This form should be used only by victims services professionals and other advocates who wish to be trained and certified as an Application Assistant. Please contact the Safe at Home Program directly for more information regarding upcoming training sessions or to schedule a training in your area. 

 

Helpful Information

Program Overview

Safe at Home Application Checklist

Eligibility and Application Requirements

Essential Information for State and Local Government Officials

Essential Information for Public Utility Officials

How to Make the Most of Your Program Participation

 

If you have questions about any of the information contained on this page, please contact the Safe at Home Program directly for additional assistance.