45-14a - Oregon Marriage Record Order Form (Page 2 of 3) in pdf

Oregon Marriage Record

ORDER FORM

Number of certified records requested.

Center for Health Statistics

$25 first record/$20 each additional copy

QUANTITY

of the same record ordered at the same time.

1. Bride/Partner A’s full maiden name:

(first)

(middle)

(last name at birth or maiden name)

2. Groom/Partner B’s full name:

(first)

(middle)

(last)

OREGON

3. Date of marriage:

4. Place license issued:

(mm/dd/yyyy)

(city)

(county)

OREGON

5. Place marriage occurred:

OFFICE USE ONLY

6. Your relationship to the person named on line 1:

and;

DO NOT WRITE IN THIS SPACE

7. Your reason for ordering:

Certificate number:

8. Daytime telephone number:

9. Email:

Film

10. Name of person ordering:

Film (P)

11. Your address:

Computer

Indexes

12. City/State/Zip:

Index (P)

DF/CO

13. c Person ordering: Attach legible photocopy of current, valid ID or legal representative

document and representative’s ID. See back of form for alternative ID options.

Refund: $

14. Required signature of person ordering:

 Excess fee

 Out/state

In accordance with law — ORS 432.380, only the person named on the record, immediate

 No record

 Uncompleted

family members, legal representatives and government agencies are eligible to access

Check #:

marriage records. For all others, access to marriage records is restricted for 50 years. Legal

guardians must enclose a copy of the legal document and representative’s ID. If you are not

File date:

Amendment fee:

eligible, enclose a written permission note with a notarized signature of an eligible person.

NRL/Ref issued:

Full issued:

Send to:

Make checks/money orders payable to:

OREGON VITAL RECORDS

OHA/Vital Records

PO BOX 14050

PLEASE DO NOT SEND CASH

Follow-up:

Computer copy:

PORTLAND OR 97293-0050

Checks/money orders in U. S. Dollars

Non-Sufficient Funds (NSF) check

WARNING : Providing false information is a felony under ORS 432.993.

processing policy: In the event

that your check is returned unpaid

$25 FOR THE FIRST RECORD; $20 FOR EACH ADDITIONAL COPY OF THE SAME

for insufficient or uncollected

RECORD ORDERED AT THE SAME TIME. The $25 fee is non-refundable once the

funds, we may present your check

search for the record has been completed. OAR 333-011-0340(1).

electronically. In the ordinary

course of business, your check will

This form available in alternative formats. See back for details.

not be provided to you with your

bank statement, but a copy can

be retrieved by other means. A

penalty, not to exceed $35, may be

ENTER YOUR MAILING ADDRESS

assessed for NSF checks per ORS

THIS SECTION WILL BE DETACHED AND USED AS A MAILING LABEL

30.701(5).

Name

Street

City

State

ZIP

45-14A (01/16)

45-14a - Oregon Marriage Record Order Form Page 2

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