Application For License And Certificate Of Marriage (Page 2 of 2) in pdf

Application For License And Certificate Of Marriage Page 2

APPLICATION FOR LICENSE AND CERTIFICATE OF MARRIAGE

MUST BE LEGIBLE

1A. FIRST NAME

1B. MIDDLE

1C. CURRENT LAST

1D. LAST NAME AT BIRTH (IF DIFFERENT THAN 1C)

2. DATE OF BIRTH (MM/DD/CCYY)

3. STATE/COUNTRY OF BIRTH

4. # PREV. MARRIAGES / SRDP

5A. LAST MARRIAGE / SRDP ENDED BY:

5B. DATE ENDED (MM/DD/CCYY)

DEATH

DISSO

ANNULMENT

TERM SRDP

N/A

6. ADDRESS

7. CITY

8. STATE / COUNTRY

9. ZIP CODE

10A. FULL BIRTH NAME OF FATHER / PARENT

10B. STATE OF BIRTH (IF OUTSIDE U.S., ENTER COUNTRY)

11A. FULL BIRTH NAME OF MOTHER / PARENT

11B. STATE OF BIRTH (IF OUTSIDE U.S., ENTER COUNTRY)

12A.FIRST NAME

12B. MIDDLE

12C. CURRENT LAST

12D. LAST NAME AT BIRTH (IF DIFFERENT THAN 12C)

13. DATE OF BIRTH (MM/DD/CCYY)

14. STATE/COUNTRY OF BIRTH

15. # PREV. MARRIAGES / SRDP

16A. LAST MARRIAGE / SRDP ENDED BY:

16B. DATE ENDED (MM/DD/CCYY)

DEATH

DISSO

ANNULMENT

TERM SRDP

N/A

17. ADDRESS

18. CITY

19. STATE / COUNTRY

20. ZIP CODE

21A. FULL BIRTH NAME OF FATHER / PARENT

21B. STATE OF BIRTH (IF OUTSIDE U.S., ENTER COUNTRY)

22A. FULL BIRTH NAME OF MOTHER / PARENT

22B. STATE OF BIRTH (IF OUTSIDE U.S., ENTER COUNTRY)

WE, THE UNDERSIGNED DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT WE ARE UNMARRIED AND THAT THE FOREGOING INFORMATION IS TRUE AND CORRECT

TO THE BEST OF OUR KNOWLEDGE AND BELIEF. WE FURTHER DECLARE THAT NO LEGAL OBJECTION TO THE MARRIAGE NOR TO THE ISSUANCE OF A LICENSE IS KNOWN TO US. WE ACKNOWLEDGE RECEIPT

OF THE INFORMATION REQUIRED BY FAMILY CODE SECTION 358 AND HEREBY APPLY FOR A LICENSE AND CERTIFICATE OF MARRIAGE.

23. SIGNATURE OF PERSON LISTED IN FIELDS 1A-1D

24. SIGNATURE OF PERSON LISTED IN FIELDS 12A-12D



25. ISSUE DATE

26. EXPIRES AFTER (MM/DD/CCYY)

27. MARRIAGE LICENSE NUMBER

28. CLERK ISSUING LICENSE

NEW MIDDLE AND LAST NAME OF PERSON LISTED IN 1A-1D (IF ANY) FOR USE UPON SOLEMNIZATION OF THE MARRIAGE

29A. FIRST – MUST BE SAME AS 1A

29B. MIDDLE

29C. LAST