AFFIDAVIT OF INABILITY TO APPEAR
AND REQUEST FOR ISSUANCE OF A
Check one of the following:
[ ] CONFIDENTIAL MARRIAGE LICENSE PURSUANT TO FAMILY CODE SECTION 502
[ ] PUBLIC MARRIAGE LICENSE PURSUANT TO FAMILY CODE SECTION 426
We, the undersigned, do hereby declare:
that __________________________________________________________________________
(Print Full Legal Name(s) of Person(s) Unable to Appear)
is/are physically unable to appear in person at the County Clerk’s Office to apply for a marriage license due to:
Check one of the following:
[ ]
Hospitalization (must attach proof of hospitalization)
[ ]
Incarceration
[ ]
Other _________________________________________________________
(Reason Proved to the Satisfaction of the County Clerk)
and hereby request the marriage license be issued to __________________________________________
(Print Name of Person Solemnizing Marriage)
as the officiant who will be solemnizing the marriage.
__________________________________________________________
________________________
(Print Full Legal Name of First Person)
(Date of Birth (MM/DD/CCYY))
_________________________________________________________
________________________
(Print Full Legal Name of Second Person)
(Date of Birth (MM/DD/CCYY))
We certify under penalty of perjury under the laws of the State of California that the foregoing information is true and correct:
Executed on: ___________________________ at _________________________________________________
(MM/DD/CCYY)
City/State
►______________________________________
(Signature of First Person)
Executed on: ___________________________ at _________________________________________________
(MM/DD/CCYY)
City/State
►______________________________________
(Signature of Second Person)
Executed on: ___________________________ at __________________________________________________
(MM/DD/CCYY)
City/State
►______________________________________
(Signature of Person Solemnizing Marriage)
NOTE:
The person solemnizing the marriage must physically present the completed affidavit to the County Clerk at the
time the marriage license is issued [Family Code Sections 426(a); 502(a)].
The signature(s) of the person(s) who is/are physically unable to appear in person at the County Clerk’s Office
must be authenticated by a Notary Public or a Court prior to the County Clerk issuing the marriage license
[Family Code Sections 426(c); 502(c)].
NOTE: Government Code (GC) Section 8224(a) prohibits the notary public who has authenticated the
signature(s) of the person(s) who is/are unable to physically appear in person at the County Clerk’s Office from
also being the person solemnizing the marriage.
Pursuant to Family Code Section 500, couples applying for a Confidential Marriage License must already be
living together as spouses.
CALIFORNIA DEPARTMENT OF PUBLIC HEALTH - VITAL RECORDS
VS117Be (01/2017)
1
Affidavit Of Records Custodian Certifying Records Pursuant To Rules Of Evidence 803(6) And 902(11)
Legal
