Fillable Marriage License Application printable pdf download

STATE OF MINNESOTA

BOOK NO.

HUBBARD

COUNTY

MARRIAGE LICENSE APPLICATION

PAGE NO.

(YOU MUST PRINT IN BLACK INK)

LICENSE VALID FOR SIX MONTHS FROM DATE OF ISSUE – NO REFUNDS

NAME (FIRST)

(MIDDLE)

(LAST)

SEX

FULL LEGAL

NAME

ADDRESS (NUMBER & STREET)

SOCIAL SECURITY NUMBER

I CERTIFY THAT I DO NOT

HAVE A SOCIAL SECURITY

NUMBER:

(check box)

CITY, VILLAGE OR TOWNSHIP

COUNTY

STATE

ZIP CODE

AGE

BIRTH DATE

COMPLETE DATE OF LAST

HOW WAS LAST MARRIAGE TERMINATED?

COUNTY, STATE & COURT OF TERMINATION

PREVIOUS MARRIED NAME

TERMINATION

DEATH

DISSOLUTION

ANNULMENT

NAME (FIRST)

(MIDDLE)

(LAST)

SEX

FULL LEGAL

NAME

ADDRESS (NUMBER & STREET)

SOCIAL SECURITY NUMBER

I CERTIFY THAT I DO NOT

HAVE A SOCIAL SECURITY

NUMBER:

(check box)

CITY, VILLAGE OR TOWNSHIP

COUNTY

STATE

ZIP CODE

AGE

BIRTH DATE

HOW WAS LAST MARRIAGE TERMINATED?

COMPLETE DATE OF LAST

COUNTY, STATE & COURT OF TERMINATION

PREVIOUS MARRIED NAME

TERMINATION

DEATH

DISSOLUTION

ANNULMENT

IF EITHER APPLICANT IS A MINOR, NAME AND ADDRESS OF THE MINOR’S PARENTS OR GUARDIAN.

ARE THE APPLICANTS RELATED TO

IF YES, STATE RELATIONSHIP

YES

NOTICE:

Marriage must be performed

EACH OTHER BY BLOOD OR ADOPTION

within the geographical borders of Minnesota.

COMPLETE ADDRESS OF APPLICANTS AFTER MARRIAGE

(MN Statutes 517.07)

STREET:

CITY/STATE/ZIP:

Federal and state law require that an applicant’s Social Security number, if any, be collected on the marriage license application. 42 U.S.C. § 666 (a)(13)(A), Minn. Stat. §§ 144.223, 517.08 subd.

1a(8). If you have a Social Security number, you are required to provide it. State law requires this number be reported to the Minnesota Department of Health, and it will be kept private. If

necessary, your Social Security number may be used to help obtain financial support for your child.

Minnesota Statute 259.13, subdivision 1, requires a person who committed a felony crime under any law to serve a notice of application for a name change on the prosecuting authority for the

crime when seeking a name change as a part of the marriage license. If the prosecuting authority is located in another state, the Attorney General must also be served.

Minnesota Statute 259.115, provides that if a person who committed a felony crime under any law uses a different surname after marriage than what was used before marriage, without complying

with section 259.13, is guilty of a gross misdemeanor.

Minnesota Statute 517.08, subdivision 1b, provides that if a person committed a felony crime under any law is applying for a marriage license, the court administrator shall either grant the marriage

license without the requested name change or delay its granting until the person: (1) certifies that 30 days have passed since the notice of name change upon the prosecuting authority, and if

applicable, the Attorney General, and no objections have been made; or (2) provides a certified copy of a court granting the name change. The parties seeking the marriage license have the choice of

whether to have the license granted without the name change or to delay its granting pending further action on the name change request.

COMPLETE NAMES OF APPLICANTS AFTER MARRIAGE

FIRST APPLICANT:

(FIRST)

(MIDDLE)

(LAST)

SECOND APPLICANT: (FIRST)

(MIDDLE)

(LAST)

Does one or both of the applicants have a felony conviction under Minnesota law or the law of another state or federal jurisdiction?

FIRST APPLICANT

YES

NO If yes, Jurisdiction ________________

SECOND APPLICANT

YES

NO If yes, Jurisdiction________________________

If either APPLICANT has committed a felony crime under any law and is assuming a different name after marriage, proof of service of a notice of application for a name

change as required by Minnesota Statutes 259.13, 259.115, and 517.08 must be attached.

Attach copy of Proof of Service . Dates of Service_____________________

Deputy Registrar: _________________

I hereby solemnly affirm that I have read and understood the statutes written above, and swear that I either have committed no felony crimes under

any law or if I have committed a felony crime, that I have fully complied with the notice of name change as required by Minnesota statutes,

AND

I hereby solemnly affirm, under penalty of perjury, that all of the above statements of fact are true in every respect; that we are no nearer of kin

than the first cousins once removed; that neither is committed to the guardianship or conservatorship of the commissioner of human services for

reason of developmental disability, without written consent of the commissioner of human services if necessary pursuant to Minn. Stat. § 517.03

subd. 2; that there will be no legal impediment to this marriage on the date the license is valid; and that neither of us has a spouse living.

r r r r

____________________________________________________

signature

FIRST APPLICANT

SECOND APPLICANT

(must be signed in the presence of a Notary/Deputy)

UBSCRIBED AND SWORN TO BEFORE ME THIS

________DAY OF _______________________, 20____.

______________________________________________

NOTARY/DEPUTY

______________

_______________

DATE OF APPLICATION

DATE LICENSE ISSUED

PLACE OF MARRIAGE ____________________________

Marriage License Application

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