Form Vs113 - San Benito County Clerk Marriage Licenses - 2015 Page 2

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APPLICATION FOR PUBLIC MARRIAGE LICENSE
1A. FIRST NAME
1B. MIDDLE
1C. CURRENT LAST
1D. LAST NAME AT BIRTH (IF DIFFERENT THAN 1C)
2. DATE OF BIRTH (MM/DD/CCYY)
3. STATE/COUNTRY OF BIRTH 4. #PREV. MARRIAGES/SRDP 5A. LAST MARRIAGE/SRDP ENDED BY:
5B. DATE ENDED (MM/DD/CCYY)
 DEATH  DISSO  ANNULMENT  TERM SRDP  N/A
6. ADDRESS
7. CITY
8. STATE/COUNTRY
9. ZIP CODE
10A. FULL BIRTH NAME OF FATHER/PARENT
10B. STATE OF BIRTH (IF OUTSIDE U.S. ENTER COUNTRY)
11A. FULL BIRTH NAME OF MOTHER/PARENT
11B. STATE OF BIRTH (IF OUTSIDE U.S. ENTER COUNTRY)
12A. FIRST NAME
12B. MIDDLE
12C. CURRENT LAST
12D. LAST NAME AT BIRTH (IF DIFFERENT THAN 12C)
13. DATE OF BIRTH (MM/DD/CCYY) 14. STATE/COUNTRY OF BIRTH 15. # PREV. MARRIAGES/SRDP 16A. LAST MARRIAGE/SRDP ENDED BY:
16B. DATE ENDED (MM/DD/CCYY)
 DEATH  DISSO  ANNULMENT  TERM SRDP  N/A
17. ADDRESS
18. CITY
19. STATE/COUNTRY
20. ZIP CODE
21A. FULL BIRTH NAME OF FATHER/PARENT
21B. STATE OF BIRTH (IF OUTSIDE U.S. ENTER COUNTRY)
22A. FULL BIRTH NAME OF MOTHER/PARENT
22B. STATE OF BIRTH (IF OUTSIDE U.S. ENTER COUNTRY)
WE, THE UNDERSIGNED DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT WE ARE UNMARRIED AND THAT THE FOREGOING
INFORMATION IS TRUE AND CORRECT TO THE BEST OF OUR KNOWLEDGE AND BELIEF. WE FURTHER DECLARE THAT NO LEGAL OBJECTION TO THE MARRIAGE NOR TO THE
ISSUANCE OF A LICENSE IS KNOWN TO US. WE ACKNOWLEDGE RECEIPT OF THE INFORMATION REQUIRED BY FAMILY CODE SECTION 358 AND HEREBY APPLY FOR A LICENSE
AND CERTIFICATE OF MARRIAGE.
23. SIGNATURE OF PERSON LISTED IN FIELDS 1A-1D
24. SIGNATURE OF PERSON LISTED IN FIELDS 12A-12D
THIS FIELD RESERVED FOR USE BY COUNTY CLERK STAFF:
ISSUE DATE (MM/DD/CCYY)
MARRIAGE LICENSE NUMBER
BY
NEW MIDDLE AND LAST NAME OF PERSON LISTED IN 1A-1D (IF ANY) FOR USE UPON SOLEMNIZATION OF THE MARRIAGE (SEE REVERSE FOR INFORMATION)
30A. FIRST – MUST BE SAME AS 1A
30B. MIDDLE
30C. LAST
NEW MIDDLE AND LAST NAME OF PERSON LISTED IN 12A-12D (IF ANY) FOR USE UPON SOLEMNIZATION OF THE MARRIAGE (SEE REVERSE FOR INFORMATION)
31A. FIRST – MUST BE SAME AS 12A
31B. MIDDLE
31C. LAST
DO NOT WRITE IN THIS BOX – FOR OFFICIAL USE ONLY
LICENSE/I.D.
________________________________
LICENSE/I.D.
________________________________
NAME:
________________________________
NAME:
________________________________
ISSUE DATE:
________________________________
ISSUE DATE:
________________________________
EXPIRATION DATE: ________________________________
EXPIRATION DATE: ________________________________
TELEPHONE NO.:
________________________________
TELEPHONE NO.:
________________________________
To ensure that the correct marriage license is issued to you, please provide the information requested below:
The person performing this marriage ceremony is (check one):
__ Clergy person (minister, priest, rabbi, etc.)
__ Judge
__ Commissioner or Deputy commissioner of civil marriages
__ Other (specify) _________________________________
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