Marriage License Application Information Review Form

Disclosure of Social

STATE OF INDIANA

Security Number required

MARRIAGE LICENSE APPLICATION

IC 31-11-4-4

INFORMATION REVIEW

No.: _________

Application Date:_________

___________________County

VERMILLION

Information confidential

pursuant to IC 16-37-1-10

MALE APPLICANT

FEMALE APPLICANT

Yes/No

1. Are you now or have you ever been adjudged to be of unsound

______

1. Are you now or have you ever been adjudged to be of unsound mind?

______

mind?

______

If yes, has the adjudication been removed?

______

If yes, has the adjudication been removed?

2. Are you related to the co-applicant closer than second cousin?

______

2. Are you related to the co-applicant closer than second cousin?

______

If yes, are you first cousins over the age of 65?

______

If yes, are you first cousins over the age of 65?

______

3. Are you now under the influence of an alcoholic beverage?

____

4. Are you now under the influence of a narcotic drug?

____

________________________________________

__________________________________________

Name:

_____________

_____-____-________

______________

_____-____-________

Date of Birth:

SSN:

Date of Birth:

SSN:

__________________________

____________________________

Date of Birth Verified by

: ___________________________________

: _____________________________________

Birth place

___________________________________

_____________________________________

Residence

___________________________________

_____________________________________

___________________________________

_____________________________________

: _____________________

______

: _____________________

______

County

In City Limits?

County

In City Limits?

: ______________________

Race

____________________

_____________________

Ethnicity:

Education (highest

grade completed)

_____________________________

________________________________

Usual Occupation

______

:________

______

:________

# Previous Marriages:

Last Marriage Ended By

# Previous Marriages:

Last Marriage Ended By

_______________________

________________________

Date Last Marriage Ended:

Dependent Children (List full names of each):

____________________________________________

______________________________________________

____________________________________________

______________________________________________

____________________________________________

______________________________________________

____________________________________________

______________________________________________

Father’s Full Name (if

adopted, list adoptive father

Father’s Full Name (if adopted,

_________________________

only):

list adoptive father only):

_______

Father Deceased?

__________________________________

_____________________________________

Last known

__________________________________

_____________________________________

Residence of

__________________________________

_____________________________________

Father

Father’s Birth

_______________________________

Place:

Father’s Birth Place:

Mother’s Full Name (if

adopted, list adoptive mother

Mother’s Full Name (if adopted,

_________________________

only)

list adoptive mother only)

_______

Mother Deceased?

__________________________________

_____________________________________

Last known

__________________________________

_____________________________________

Residence of

__________________________________

_____________________________________

Mother

Mother’s Birth

_______________________________

Place:

Mother’s Birth Place:

Mother’s Maiden Name_____________________________________________

Mother’s Maiden Name ________________________________________________

Marriage License Application Information Review Form - Indiana

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