Written Application For Unrestricted Certified Copy Of A Marriage Record - 2014

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WRITTEN APPLICATION FOR UNRESTRICTED CERTIFIED COPY

OF A MARRIAGE RECORD

PLEASE REVIEW THE INSTRUCTIONS ON THE BACK BEFORE COMPLETING

Marriage Certificate Information: Fee: $15.00 per copy Number of copies requested: ___________

First Person:

________________________________________________________________________________________

First

Middle

Last (Maiden name if applicable)

Second Person: __________________________________________________________________________________________

First

Middle

Last (Maiden name if applicable)

Date of Marriage: ______________________________________________

County Where License Was Issued: _______________________________

Applicant Information (Your name and address):

Name: _______________________________________________________________________________________________

First

Middle

Last

Address: ______________________________________________________________________________________________

Number and Street

City

State

Zip Code

Mailing Address: _______________________________________________________________________________________

If different than above

Number and Street

City

State

Zip Code

Telephone Number: (_____)_____________________ Email: ______________________________________

With Area Code

To obtain an Unrestricted Certified Copy you must be authorized under section 103526 of the Health and Safety

Code. Please review the reverse side of this application to determine which section applies and check the

appropriate box below

103526(c)(1)

103526(c)(2)

103526(c)(3)

103526(c)(4)

103526(c)(5)

I, _______________________________ swear under penalty of perjury that I am an authorized person, as

Printed Name

defined in California Health and Safety Code Section 103526(c), and am eligible to receive a certified copy of the

marriage record identified on this application form. Sworn this ____ day of ______________________, _________,

at __________________________________________

Signature: ___________________________________

A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate

is attached, and not the truthfulness, accuracy, or validity of that document.

Certificate of Acknowledgement

State of ____________________ County of _________________

On ________________ before me, ______________________, personally appeared _________________________

who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and

acknowledged to me that he/she executed the same in his/her authorized capacity, and that by his/her signature on the instrument

the person, or the entity upon behalf of which the person acted, executed the instrument. I certify under PENALTY OF

PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and

official seal.

______________________________________

Signature

(seal)