Form Dh-Phs-Marapp-2012 - Application For Vermont License Of Civil Marriage

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DH-PHS-MARAPP-2012

VERMONT DEPARTMENT OF HEALTH

APPLICATION FOR VERMONT LICENSE OF CIVIL MARRIAGE

FEE FOR CIVIL MARRIAGE LICENSE $45.00

APPLICANT A

BRIDE

GROOM

SPOUSE

(check one)

1a. LEGAL NAME (First, Middle, Last)

1b. LAST NAME AT BIRTH (Maiden Surname)

2. SEX

3. DATE OF BIRTH (Month, Day, Year)

4. BIRTHPLACE (State or Foreign Country)

5a. RESIDENCE ADDRESS (Number and Street)

5b. CITY OR TOWN OF RESIDENCE

5c. STATE OF RESIDENCE

5d. COUNTRY OF RESIDENCE

6a. FATHER’S OR PARENT’S NAME (First, Middle, Last Name at Birth)

6b. BIRTHPLACE (State or Foreign Country)

7a. MOTHER’S OR PARENT’S NAME (First, Middle, Last Name at Birth)

7b. BIRTHPLACE (State or Foreign Country)

APPLICANT B

BRIDE

GROOM

SPOUSE

(check one)

8a. LEGAL NAME (First, Middle, Last)

8b. LAST NAME AT BIRTH (Maiden Surname)

9. SEX

10. DATE OF BIRTH (Month, Day, Year)

11. BIRTHPLACE (State or Foreign Country)

12a. RESIDENCE ADDRESS (Number and Street)

12b. CITY OR TOWN OF RESIDENCE

12c. STATE OF RESIDENCE

12d. COUNTRY OF RESIDENCE

13a. FATHER’S OR PARENT’S NAME (First, Middle, Last Name at Birth)

13b. BIRTHPLACE (State or Foreign Country)

14a. MOTHER’S OR PARENT’S NAME (First, Middle, Last Name at Birth)

14b. BIRTHPLACE (State or Foreign Country)

THE CONFIDENTIAL INFORMATION BELOW MUST BE COMPLETED. IT WILL NOT APPEAR ON CERTIFIED COPIES OF THE RECORD.

APPLICANT A

22. TOTAL NO. OF MARRIAGES AND CIVIL

23a. LAST MARRIAGE OR CIVIL UNION ENDED BY (check one)

23b. DATE LAST MARRIAGE OR CIVIL UNION ENDED

UNIONS, INCLUDING THIS ONE

Death

Divorce

Dissolution

Annulment

Civil union did not end;

Month _________________________ Year _________

marrying civil union partner

APPLICANT B

25. TOTAL NO. OF MARRIAGES AND CIVIL

26a. LAST MARRIAGE OR CIVIL UNION ENDED BY (check one)

26b. DATE LAST MARRIAGE OR CIVIL UNION ENDED

UNIONS, INCLUDING THIS ONE

Death

Divorce

Dissolution

Annulment

Civil union did not end;

Month _________________________ Year _________

marrying civil union partner

DOES EITHER APPLICANT HAVE A LEGAL GUARDIAN?

____YES ____ NO

18 V.S.A. § 5131 (4)(A) provides that "parties to a civil union certified in Vermont may elect to dissolve their civil union upon marrying one

another but are not required to do so to form a civil marriage." The option to elect dissolution of the civil union is found in the confidential

section of the marriage license and shall become effective upon solemnization of the marriage.

APPLICANTS

We/I hereby certify that the information provided is correct to the best of our/my knowledge and belief and that we are free to marry under the laws of Vermont.

15a. SIGNATURE (Applicant A)

15b. DATE SIGNED

16a. SIGNATURE (Applicant B)

16b. DATE SIGNED

15c. TELEPHONE NUMBER

15d. E-MAIL ADDRESS

16c. TELEPHONE NUMBER

16d. E-MAIL ADDRESS

Planned marriage date ________________________________ Location (City or Town) _______________________________________________

Officiant name and mailing address _________________________________________________________________________________________

Your mailing address after wedding _________________________________________________________________________________________

Do you want a certified copy of your Civil Marriage Certificate ($10.00) _____ Yes _____ No