State Of New York - Information Required For Marriage License
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1
2State of New York
Information Required for Marriage License
BRIDE/GROOM/SPOUSE INFORMATION:
FULL NAME: __________________________________________________ Social Security Number: _____-_____-_____
SURNAME (after marriage):_______________________________ BIRTH NAME (if Different): _________________________
Residence Address: ____________________________________
Mailing Address:________________________________
City: ___________________________________
City:_____________________________
State: _____________ Zip Code: _____________
State:_________
Zip Code: ___________
County: _________________________________
Phone No.: (_____)_______-_________
Is residence within limits of a city of incorporated village? (Check one) _____YES ______NO
AGE:___________
DATE OF BIRTH: ______/______/______
SEX: (Optional)_______________
(mm/dd/yy)
USUAL OCCUPATION: ___________________________________________________________________________
TYPE OF INDUSTRY OR BUSINESS: __________________________________________________________________
PLACE OF BIRTH: ___________________________________________
(City & State as stated on Birth Certificate)
FATHER OR PARENT INFORMATION:
Full Name: ____________________________________________ Country of Birth: __________________________
MOTHER OR PARENT INFORMATION:
Full Name: ____________________________________________ Country of Birth: __________________________
PREVIOUS MARRIAGE INFORMATION:
Number of this Marriage: _______
Number of Previous Marriages which ended by: Divorce:_____
Civil Annulment:_____
Death:_____
How did last marriage end? (Check one): ____ Divorce _____Annulment _____ Death
Date last marriage ended : ______/______/______
(mm/dd/yy)
Are any former spouses alive? (Check one): _______YES
_______NO
If previously divorced or annulled, provide the following information:
Against Whom
Date of Decree
Place Issued (City, State/County if not USA)
Self
Spouse
1st:
/
/
2nd:
/
/
3rd:
/
/
4th:
/
/
ACTIVE DUTY? (Check one): ________Yes _________No
I declare that to the best of my knowledge and belief the information I provided is true and complete:
Signature of Bride/Groom/Spouse: ______________________________________________________
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