Registration Affidavit For Premarital Course Provider Form - Florida

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C
T
AROLYN
IMMANN
Clerk of the Circuit Court & Comptroller
Martin County
Florida
P. O. BOX 9016
STUART, FLORIDA 34995
(772) 288-5576
Registration Affidavit for Premarital Course Provider
1. Affiant Name: ______________________________________________ Title: ____________________________
Affiant Business Address: _____________________________________________________________________
Affiant Contact Telephone Number: ______________________ Email: _________________________________
Organization/Church Name: ___________________________________________________________________
2. The premarital course provider’s qualifications are:
(Check applicable qualification(s) and provide license number where indicated)
A psychologist licensed under Chapter 490, Florida Statutes. License# ____________________________
A clinical social worker licensed under Chapter 491, Florida Statutes. License#______________________
A marriage and family therapist licensed under Chapter 491, Florida Statutes. License# _______________
A mental health counselor licensed under Chapter 491, Florida Statutes. License# ___________________
An official representative of a religious institution which is recognized under Florida Statute 496.404(23). This
official has the following relevant training:_________________________________________________________
_____________________________________________________________________________________________
__________________________________________________________________________________________
Any other provider designated by a judicial circuit, including but not limited to, school counselors who are
certified to offer such courses. License# __________________________________________________________
Under penalty of perjury, I hereby certify and attest that I am in compliance with the premarital preparation course
requirements as set forth in section 741.0305, Florida Statutes.
Affiant Signature __________________________________________________ Date ____________________________
STATE OF FLORIDA
COUNTY OF ___________________
Sworn to and subscribed before me this _____ day of ____________, 20 ____, by ______________________________,
who is
personally known to me or
who has produced the following identification: __________________________
__________________________________________.
___________________________________
(Signature of Notary Public/Deputy Clerk)
(SEAL)
___________________________________
(Printed Name)
Please return completed affidavit to:
Clerk of the Circuit Court & Comptroller
Attention: Official Records Division
P.O. Box 9016
Stuart, Florida 34995

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