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Office of the County Clerk
License No._________________
Lynn Marie Goya
County Clerk
AFFIDAVIT FOR ISSUANCE OF MARRIAGE LICENSE TO ONE PARTY
State of Nevada
)
)§:
County of Clark )
The undersigned, being duly sworn, provides the following information for the issuance of a Marriage License
pursuant to NRS 122.040 Subsection 3.
Name:
First________________________ Middle ______________________ Last ______________________________________
Male _______ Female _______
Inmate Number _______________(if applicable)
Resident City and State _______________________________________
Date of Birth _________________Age_____ Birth State ____________________ Birth Country ________________________
Social Security Number ______________________________
No. of this marriage _______
Marital Status: ____Never Married ____Divorced ____ Widowed
____Annulled
Final date of the last marriage ended ________________________ City/State __________________________________
Parent’s Name(s):
Father’s First Name __________________________Middle __________________Last ___________________________
State of Birth _______________________________________ Country ________________________________________
Mother’s First Name _________________________Middle __________________Maiden _________________________
State of Birth _______________________________________ Country ________________________________________
Mailing Address: ____________________________________________________________________________________
I am unable to be present for the issuance of the Marriage License because:
__________________________________________________________________________________________________
I wish to marry _________________________________________. No blood relationship exists between the two
of us closer than that allowed by law. I am free to marry and no legal objection exists to this marriage.
________________________________________
(Signature of Absent Party)
SUBSCRIBED AND SWORN to before me
this _______ day of _______________, 20____.
_______________________________________________
Notary Public
Revised 01-06-15
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