Form Acr 485 - Application For Certified Copy Or Search Of A Marriage Record - 2014

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RIVERSIDE COUNTY
ASSESSOR-COUNTY CLERK-RECORDER
APPLICATION FOR CERTIFIED COPY OR SEARCH OF A MARRIAGE RECORD
PLEASE REVIEW THE INSTRUCTIONS ON THE BACK BEFORE COMPLETING
PLEASE PRINT IN BLACK OR BLUE INK
MARRIAGE RECORD or CERTIFICATE OF NO RECORD INFORMATION
FEE $15.00
1
PLEASE PRINT
License # __________________________________
Type of License Purchased:
Public
Confidential
If requesting a Certificate of No Record, years to be searched: _______________________to__________________________
For below, give names prior to this marriage:
Name of First Person: __________________________________________________________________________________
First
Middle
Last
Name of Second Person: ________________________________________________________________________________
First
Middle
Last
Date of Marriage:____________________________________ Number of Copies____________________________________
I am requesting an AUTHORIZED copy
I am requesting an INFORMATIONAL copy
2
If you are requesting an Informational copy, please skip to section 4.
Public Marriage Certificate: To receive a Certified Copy I am:
Confidential marriage certificate:
3
To receive a Certified Copy I am:
The registrant (one of the parties to the marriage).
A parent, legal guardian, child, grandparent, grandchild, sibling, spouse, or domestic
One of the parties to the confidential
partner of the registrant
marriage
A member or representative of a government agency, as provided by law, who is
A party entitled to receive the record as a
conducting official business.
result of a court order (include a certified
A party entitled to receive the record as a result of a court order (include a certified
copy of the court order with this request)
copy of the court order with this request).
An attorney representing the registrant or the registrant’s estate, or any person or
agency empowered by statute or appointed by a court to act on behalf of the
registrant or the registrant’s estate (if by power of attorney, include a copy of the
power of attorney with this request)
Those who are not authorized by law to receive a certified copy of a non-confidential (public)
marriage record will receive a certified copy marked “INFORMATIONAL, NOT A VALID
DOCUMENT TO ESTABLISH IDENTITY”
Requested by:
Mail/Issue To: (For Public Marriages Only)
4
_________________________________________________
________________________________________
Name
Name of Person Receiving Copies, If Different from Applicant
_________________________________________________
________________________________________
Street Address
Mailing Address for Copies, if Different from Applicant
_________________________________________________
________________________________________
City
State
Zip
City
State
Zip
_____________________________________
Phone # (_________)_____________________________
I.D. #
5
I, ______________________________________________ swear or affirm under penalty of perjury that I am an authorized person, as defined in
(Print Full Name)
California Health and Safety Code Section 103526 (c), eligible to receive a certified copy of the marriage record identified on this application form.
Sworn: __________________________________________ at __________________________________
____________
Date (mm/dd/ccyy)
City
State
Signature: ___________________________________________________________________________________________
(Applicant Signature)
(If ordering in person you must sign in front of the Clerk)
BELOW SECTION FOR OFFICE USE ONLY
Receipt #
Check #
Total $ Due
Amount Paid
Year / Certificate #
Cash
Check Debit / Credit
Long Amount
Refund Amount
Counter
Mail
Gov’t Agency
Govt. Stamped
Credit Card # / Exp. Date
Type of I.D., Identifying Numbers and Exp. Date
Clerks Initials
Do Not Charge Fee, Contact State
Charge Search Fee, Contact
State or ________________ Searched years from ___________ to ____________ by: ____________
ACR 485 (Rev. 11/2014)
Available in Alternate Formats

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