R72 - Marriage License Application - County Of Los Angeles
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4Marriage License Application
City Ceremony Will Take Place:
___________________________
Date of Ceremony:
___________________________
License Type applying for:
Public - $90.00 (Record will become public record once recorded)
Confidential - $85.00 (Record will be closed, and not opened to public once recorded- must be living together)
Other - $90.00 - For Denomination without Clergy (Buddhist, Muslim, Bahai, etc.)
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1
PERSON PERSONAL DATA
2
PERSON PERSONAL DATA
Optional:
□Bride
□Groom □None
Optional:
□Bride
□Groom □None
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Person’s ID or DL#
Exp:
2
Person’s ID or DL#
Exp:
First Name:
First Name:
Middle Name:
Middle Name:
Current Last Name:
Current Last Name:
Last Name At Birth (If Different):
Last Name at Birth (If Different):
Date of Birth:
State of Birth:
Date of Birth:
State of Birth:
Number of Previous Marriages/SRDP:
Number of Previous Marriages/SRDP:
Last Marriage/SRDP Ended By (1):
Last Marriage/SRDP Ended By (1):
Death
Divorce
Annulment
Death
Divorce
Annulment
Date Last Marriage/SRDP Ended Month/Day/Year:
Date Last Marriage/SRDP Ended Month/Day/Year:
Father’s Full Name:
Father’s Full Name:
Father’s State of Birth:
Father’s State of Birth:
Mother’s Full Maiden Name:
Mother’s Full Maiden Name:
Mother’s State of Birth:
Mother’s State of Birth:
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Person’s Address:
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Person’s Address:
City:
Zip:
City:
Zip:
County:
County:
Mailing Address:
Mailing Address:
City:
Zip:
City:
Zip:
County:
County:
Email Address:
Daytime Phone Number:
New Middle Name (optional):
New Middle Name (optional):
New Last Name (optional):
New Last Name (optional):
We the undersigned declare that all the information above is true and correct to the best of our knowledge. We also declare that
we have read and understood the information on the reverse side of this form.
Signature ______________________
Signature ______________________
Please read reverse side
R72 Rev. 5/10
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