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.

If you are completing this application on behalf of another person, please contact the ACP Office prior to submission.

First Name (Value Required)

Middle Name

Last Name (Value Required)

Name Suffix

Birth Date [MM/DD/YYYY] (Value Required)

Day Phone (Value Required)

Evening Phone

Safe Alternate 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.

Are you a New York State resident? (Value Required)

Eligibility (Value Required)

Domestic Violence

Stalking

Sexual Offense

Human Trafficking

Reproductive Health Care Services Provider Employee, Volunteer, Patient or immediate family member of a reproductive health care services provider

Kidnapping

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.

Address1 (Value Required)

Address2

City (Value Required)

State (Value Required)

Zip Code (Value Required)

County (Value Required)

This is the address where the primary participant would like his/her mail delivered. If your mailing address is the same as your actual address, you may click the "Copy Same Address" button to copy over the information. 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.

Address1 (Value Required)

Address2

City (Value Required)

State (Value Required)

Zip Code (Value Required)

County (Value Required)

Primary Participant Information

Actual Household Address Information

Mailing Address Information