State Of Maine Intention Of Marriage

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STATE OF MAINE INTENTION OF MARRIAGE
INSTRUCTIONS: Please type or clearly print with ink. Complete every item carefully, sign the certification statement, and return an application to the municipality in
which at least one applicant resides. If neither applicant is a Maine resident, return the application to any municipality. The License and Certificate of Marriage will be
prepared from the information on this form. It is valid only for marriages performed in the State of Maine.
GROOM SECTION
1a. FIRST NAME
1b. MIDDLE NAME
1c. LAST NAME
1d. JR., ETC.
2. AGE LAST BIRTHDAY
3. RESIDENCE - State
4. COUNTY
5. CITY OR TOWN
6. STREET AND NUMBER
7. BIRTHPLACE (State or Foreign Country)
8. DATE OF BIRTH (Mo., Day, Yr.)
9. FATHER’S NAME (First, Middle Initial, Last)
10. BIRTHPLACE (State or
11. MOTHER’S NAME (First, Middle Initial, Maiden Surname)
12. BIRTHPLACE (State or
Foreign Country)
Foreign Country)
BRIDE SECTION
13a. FIRST NAME
13b. MIDDLE NAME
13c. MAIDEN SURNAME
14. CURRENT LAST NAME
15. AGE LAST BIRTHDAY
16. RESIDENCE - State
17. COUNTY
18. CITY OR TOWN
19. STREET AND NUMBER
20. BIRTHPLACE (State or Foreign Country)
21. DATE OF BIRTH (Mo., Day, Yr.)
22. FATHER’S NAME (First, Middle initial, Last)
23. BIRTHPLACE (State or Foreign
24. MOTHER’S NAME (First, Middle Initial, Maiden Surname)
25. BIRTHPLACE (State or
Country)
Foreign Country)
MARITAL STATUS SECTION
GROOM
BRIDE
Number of This Marriage
27. If Previously Married, Last Marriage Ended
Number of This Marriage
29. If Previously Married, Last Marriage Ended
26. First, Second, etc.
28. First, Second, etc.
DEATH
DIVORCE
ANNULMENT
DEATH
DIVORCE
ANNULMENT
(Specify)
(Specify)
DATE: (Mo., Day, Yr.): ________/________/________
DATE: (Mo., Day, Yr.): ________/________/________
NAME OF FORMER SPOUSE:
NAME OF FORMER SPOUSE:
Is groom currently registered with the State of Maine as a domestic
Is bride currently registered with the State of Maine as a domestic
partner?
Yes
No
If so, year registered:
partner?
Yes
No
If so, year registered:
LOCATION/NAME OF COURT:
LOCATION/NAME OF COURT:
First cousins are required by law to obtain a certificate of genetic counseling by a physician. Are you First Cousins?
Yes
No
I hereby certify that the information provided is correct to the best of my knowledge and belief and that I am free to marry under the laws
of the State of Maine.
Signature of Groom
Signature of Bride
Telephone Number:
Telephone Number:
Personally appeared before me the above named and made oath to the truth and foregoing statement:
(Signature of Notary Public/Municipal Clerk)
(Signature of Notary Public/Municipal Clerk)
My term expires:
My term expires:
State of
State of
County of
County of
Town/City of
Town/City of
Marriage is planned to take place on
at
Date (Mo., Day, Yr.)
Officiant (if known) will be:
Title:
(Religious/Civil)
Telephone # (optional)
Officiant’s Address
Street
City
State
Zip Code
Date Intentions Filed (Mo., Day, Yr.):
S:\vradminf\AMaster forms\VS2A R8/2012
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