Connecticut General Statutes Title 54. Criminal Procedure § 54-240c. Certification as program participant. Application requirements

(1) A statement made under penalty of false statement, as provided in section 53a-157b, that the applicant or the person on whose behalf the application is made (A) is a victim of (i) family violence, (ii) injury or risk of injury to a minor, (iii) kidnapping, (iv) sexual assault, (v) stalking, (vi) trafficking in persons, or (vii) child abuse or neglect, where such abuse or neglect was substantiated by the Department of Children and Families and was the basis for the issuance of a restraining order under section 46b-15 or civil protection order under section 46b-16a, or (B) a termination of parental rights was granted pursuant to section 45a-717 or 46b-129, and (C) the applicant fears for the safety of the applicant, children living in the applicant's home, person on whose behalf the application is made or children living in the home of the person on whose behalf the application is made;

(2) Documentation supporting the statement made pursuant to subdivision (1) of this section;

(3) A designation of the Secretary of the State as the agent of the applicant or the person on whose behalf the application is made for service of process and for receipt of first class mail;

(4) The residential address in this state, the work and school addresses in this state, if any, and the phone number or numbers, if available, that are to remain confidential, but which may be used by the Secretary of the State or authorized personnel to contact the applicant or the person on whose behalf the application is made; and

(5) The application preparation date, the applicant's signature and the signature of the application assistant who assisted the applicant in completing the application.