Application For Marriage License
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1APPLICATION FOR MARRIAGE LICENSE
STATE OF MINNESOTA, COUNTY OF SIBLEY
DOCUMENT #
NAME
( FIRST )
(MI DDLE)
( LAST )
SOCIAL SECURITY NO
I CERTIFY THAT I DO NOT HAVE A SOCIAL
SECURITY NUMBER Signature Required
ADDRESS ( NUMBER AND STREET )
CITY
STATE
COUNTY
ZIP
AGE
BIRTHDATE
BIRTHPLACE ( STATE OR FOREIGN COUNTRY )
SEX
RACE
M
F
NO. OF PREVIOUS
HOW LAST MARRIAGE TERMINATED
DATE TERMINATED
PLACE TERMINATED
COURT
(DEATH, DIVORCE, ANNULMENT)
(COUNTY)
(DISTRICT,CIRCUIT)
MARRIAGES
PREVIOUS MARRIED NAME ( FIRST )
( MIDDLE )
( LAST )
□
□
**DOES THE FIRST APPLICANT HAVE A FELONY
CONVICTION FOR A CRIME COMMITTED ON OR AFTER
NO
YES
AUGUST 1, 2000 UNDER MINNESOTA LAW OR THE LAW
OF ANOTHER STATE OR FEDERAL JURISDICTION:
IF YES, JURISDICTION
NAME
( FIRST )
( MIDDLE )
( LAST )
SOCIAL SECURITY NO
I CERTIFY THAT I DO NOT HAVE A SOCIAL
SECURITY NUMBER Signature Required
ADDRESS (NUMBER AND STREET )
CITY
STATE
COUNTY
ZIP
AGE
BIRTHDATE
BIRTHPLACE ( STATE OR FOREIGN COUNTRY )
SEX
RACE
M
F
NO. OF PREVIOUS
HOW LAST MARRIAGE TERMINATED
DATE TERMINATED
PLACE TERMINATED
COURT
(DEATH, DIVORCE, ANNULMENT)
(COUNTY)
(DISTRICT,CIRCUIT)
MARRIAGES
PREVIOUS MARRIED NAME ( FIRST )
( MIDDLE )
( LAST )
□
□
**DOES THE SECOND APPLICANT HAVE A FELONY
CONVICTION FOR A CRIME COMMITTED ON OR AFTER
NO
YES
AUGUST 1, 2000 UNDER MINNESOTA LAW OR THE LAW
OF ANOTHER STATE OR FEDERAL JURISDICTION:
IF YES, JURISDICTION
NAME:
IF EITHER OF THE PARTIES IS UNDER 18 YEARS OF AGE, GIVE THE NAME
AND ADDRESS OF HIS/HER CUSTODIAL PARENTS, GUARDIAN OR COURT.
ADDRESS:
(MS 517.02)
ARE THE PARTIES RELATED TO EACH OTHER BY BLOOD OR ADOPTION?
IF YES,
WHAT IS THE RELATIONSHIP?
YES
NO
FIRST APPLICANT
( FIRST )
( MIDDLE )
( LAST )
GIVE THE NAMES THE PARTIES WILL HAVE
AFTER MARRIAGE:
SECOND APPLICANT
( FIRST )
( MIDDLE )
( LAST )
ADDRESS ( NUMBER AND STREET )
ADDRESS THE PARTIES WILL HAVE
AFTER MARRIAGE: (Will not appear on marriage
CITY
STATE
ZIP
certificate, but will be mailed to this address)
STOP HERE – must take the oath in front of a Local registrar before signing.
TENNESSEN WARNING FOR THE COLLECTION OF SOCIAL SECURITY NUMBERS:
IF YOU HAVE A SOCIAL SECURITY NUMBER YOU ARE REQUIRED BY FEDERAL AND STATE LAW TO PUT IT ON THE MARRIAGE LICENSE APPLICATION (TITLE 42,
US CODE SEC 666 (a) (13) (A) , MN STATUTES, SECTION 144.223, AND MN STATUTES, SEC 517.08 SUBD 1A (1997). YOUR SOCIAL SECURITY NUMBER IS REPORTED TO
THE MN DEPARTMENT OF HEALTH AND WILL BE KEPT PRIVATE. IF NECESSARY YOUR SOCIAL SECURITY NUMBER MAY BE USED TO HELP OBTAIN FINANCIAL
SUPPORT OF YOUR CHILD.
NOTICE: A PARTY WHO HAS A FELONY CONVICTION FOR A CRIME COMMITTED ON OR AFTER AUGUST 1, 2000 UNDER MINNESOTA LAW OR THE LAW OF
ANOTHER STATE OR FEDERAL JURISDICTION MAY NOT USE A DIFFERENT NAME AFTER MARRIAGE EXCEPT AS AUTHORIZED BY MINNESOTA STATUTE 259.13,
AND DOING SO IS A GROSS MISDEMEANOR.
I, THE UNDERSIGNED, HEREBY APPLY FOR A LICENSE TO MARRY AND DECLARE UPON OATH THAT ALL OF THE ABOVE ANSWERS AND STATEMENTS OF FACT
ARE TRUE AND CORRECT; THAT NEITHER OF US HAS A SPOUSE LIVING; THAT NEITHER OF US IS A MENTALLY DEFICIENT PERSON COMMITTED TO THE
GUARDIANSHIP OR CONSERVATORSHIP OF THE COMMISSIONER OF HUMAN SERVICES.
SIGNATURE(S) X _________________________________________________________ PHONE Number (
)_____________________________
SIGNATURE(S) X _________________________________________________________ PHONE Number (
)_____________________________
SUBSCRIBED AND SWORN to before me this
day of
, 20
KATHY DIETZ, SIBLEY COUNTY RECORDER
BY: _______________________________________________________, DEPUTY
OFFICE USE ONLY
DATE
ISSUED VIA:
PAYMENT TYPE
DATE OF MARRIAGE
PLACE OF MARRIAGE
CEREMONY TYPE:
ISSUED:
MAIL
CASH
RELIGIOUS
PICK UP
CHECK
CIVIL
`
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