Ky.gov

Forms

​​​​​​​​​​​​​​​​You must use these forms to apply for the Safe at Home program, change your information, renew your certification, withdraw from the Safe at Home program, or appeal from a cancellation of certification. Please contact the Secretary of State's office at (844) 292-KACP or KACP@ky.gov if you would like to have a form emailed or mailed to you.

  •  Application for Certification - you must use this form to apply for certification to participate in the Safe at Home program and to renew your certification to participate in Safe at Home.
  • Name or Address Change - you must use this form to notify the Secretary of State's office if you change your name or address. If you do not notify the Secretary of State's office within 14 days of a change in name or address, your certification may be cancelled.
  • Withdrawal from Participation - you must use this form to withdraw from the ACP. You will receive a written confirmation of your withdrawal, and your participation will be terminated 10 days after the date of the confirmation, unless you notify the Secretary of State before that date that the withdrawal was not legitimate because it was not voluntarily submitted.
  • Appeal from Cancellation - if your certification is cancelled and you wish to appeal the cancellation, you must submit this form to the Secretary of State​'s Office. It must be received by the Secretary of State's Office within 30 days from the date of the notice of cancellation.
  • Recognition of Out of State Program- use this form if you are enrolled in an address confidentiality program in another state. Kentucky Safe at Home offers reciprocity with other states. 
  • Mail Hold Request- if you will be on vacation or away from your current residence for a short time you can request a mail hold of up to three weeks. 
  • Application Assistant Agreement - application assistants must fill this form out before aiding any potential participants of Safe at Home. 

If you need help completing any of these forms, please contact the Secretary of State's office or an authorized assistance agency.​​​