Marriage Worksheet
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1THE NAMES ON YOUR MARRIAGE LICENSE SHOULD MATCH WHAT IS ON YOUR BIRTH CERTIFICATE.
PLEASE INCLUDE FULL "LEGAL" NAMES FOR BOTH APPLICANTS AND PARENTS.
MARRIAGE WORKSHEET
APPLICANT #1 PHONE #
APPLICANT #2 PHONE #
1a . APPLICANT #1-FULL NAME (Fi rs t, Mi ddl e, La s t, Suffi x)
1b. MAIDEN LAST NAME (i f a ppl i ca bl e)
2. AGE
3a . COUNTRY
3b. STATE
3c. COUNTY
3e. ADDRESS
3d. CITY, TOWN OR LOCATION
3f. ZIP CODE
4. BIRTHPLACE (CITY AND STATE OR FOREIGN COUNTRY
5. DATE OF BIRTH (Mo,Da y,Yr)
6a . FATHER'S FULL NAME (Fi rs t, Mi ddl e, La s t, Suffi x)
6b. BIRTHPLACE (Ci ty a nd Sta te or Forei gn Country)
7a . MOTHER'S FULL MAIDEN NAME (Fi rs t, Mi ddl e, Ma i den)
7b. BIRTHPLACE (Ci ty a nd Sta te or Forei gn Country)
8a . APPLICANT #2-FULL NAME (Fi rs t, Mi ddl e, La s t, Suffi x)
9. AGE
8b. MAIDEN LAST NAME (i f a ppl i ca bl e)
10a . COUNTRY
10b. STATE
10c. COUNTY
10e. ADDRESS
10d. CITY, TOWN OR LOCATION
10f. ZIP CODE
11. BIRTHPLACE (Ci ty a nd Sta te or Forei gn Country)
12. DATE OF BIRTH (Mo,Da y,Yr)
13a . FATHER'S FULL NAME (Fi rs t, Mi ddl e, La s t, Suffi x
13b. BIRTHPLACE (Ci ty a nd Sta te or Forei gn Country)
14a . MOTHER'S FULL MAIDEN NAME (Fi rs t, Mi ddl e, La s t, Suffi x)
14b. BIRTHPLACE (Ci ty a nd Sta te or Forei gn Country)
CONFIDENTIAL INFORMATION: INFORMATION BELOW WILL NOT APPEAR ON CERTIFIED COPIES OF THIS RECORD.
15a . APPLICANT #1 - SOCIAL SECURITY NUMBER
15b. APPLICANT #2 - SOCIAL SECURITY NUMBER
16. If previ ous l y ma rri ed, l a s t ma rri a ge ended ei ther by-
APPLICANT #1: ______ Dea th ______ Di s s ol uti on ______ Annul ment
Da te Ma rri a ge Ended (mm/dd/yyyy) _______________________________
APPLICANT #2: ______ Dea th ______ Di s s ol uti on ______ Annul ment
Da te Ma rri a ge Ended (mm/dd/yyyy) _______________________________
17a . Is APPLICANT #1 of Hi s pa ni c or La ti no Ori gi n ____ Yes ____ No
17b. Is APPLICANT #2 of Hi s pa ni c or La ti no Ori gi n ____ Yes ____ No
RACE
Check one or more ra ces to i ndi ca te wha t ea ch pers on cons i ders hi m/hers el f to be:
18a . APPLICANT #1
18b. APPLICANT #2
Whi te
______
______
Bl a ck or Afri ca n Ameri ca n
______
______
Ameri ca n Indi a n or Al a s ka Na ti ve
______
______
As i a n
______
______
______
Na ti ve Ha wa i i a n or Other Pa ci fi c Is l a nder
______
The fee for the marriage license is $25. A certified copy of the marriage license is required in order for the
applicant to change their last name, e.g. Driver's License, Social Security, etc.
The cost of a certified copy is $9.
Do you want a certified copy sent to you, once it is filed in our office?
_______ YES
_______ NO
MAIL TO: Applicant #1 Address _______ Applicant #2 Address _______
Other Address: __________________________________________________
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Parent category: Business