License And Certificate Of Marriage Template (Page 2 of 2) in pdf

INSTRUCTIONS AND INFORMATION

Refunds CANNOT be given after a marriage license is issued.

You will not be notified that your license has been registered. You do not automatically receive a certified copy. You must request and pay for a

certified copy from the local registrar of marriages (County Recorder) in the county where the license was issued.

SRDP = State Registered Domestic Partnership as registered with the Secretary of State. Pursuant to Family Code, Section 298.5(c),

no person who has filed a Declaration of Domestic Partnership may enter a marriage with someone other than their registered domestic

partner unless the most recent domestic partnership has been terminated or a final judgment of dissolution or nullity has been entered, or the

domestic partnership terminated due to death of one of the domestic partners.

“New Name(s)”—Law applying to middle and last names (items 31B, 31C, 32B, and 32C) OPTIONAL: Pursuant to Family Code Section 306.5, at the

time of application for a marriage license, one or both parties to the marriage may elect to change the middle or last names, or both, by which that

party wishes to be known after solemnization of the marriage by entering that information on the marriage license application. Parties may adopt

any of the following middle names: the current last name of either spouse; the last name of either spouse given at birth; a hyphenated combination

of the current middle name and the current last name of the person or spouse; a hyphenated combination of the current middle name and the last

name given at birth of the person or spouse. Parties may adopt any of the following last names: the current last name of the other spouse; the last

name of either spouse given at birth; a name combining into a single last name all or a segment of the current last name or last name of either

spouse given at birth; a hyphenated combination of last names. NOTE: The first name of the parties may not be changed on the marriage license.

An amendment to the new name fields may only be issued to correct clerical errors, and that amendment must be signed by one of the parties to the

marriage and the county clerk or his or her deputy.

PURCHASE OF A LICENSE

All persons must purchase a License and Certificate of Declaration of Marriage from the County Clerk in the parties’ county of residence in

order to declare a California marriage which has been solemnized, but for which no official record exists (Family Code Section 425).

To Persons Declaring Their Marriage

The License and Certificate of Declaration of Marriage expires 90 days after date of issue in Item 25A and cannot be used after the

“Expiration Date” shown in Item 25B. A declared marriage is a public record. If you are declaring a marriage that originally used a Confidential

Marriage License, using this License and Certificate of Declaration of Marriage would then make it a public record.

Complete the marriage license using DARK INK ONLY.

Enter date and place of marriage in Items 26A, 26B, and 26C.

Sign your names in Items 27 and 28.

Have two witnesses to the marriage sign Items 29A and 30A and complete Items 29B, 29C, 30B and 30C.

The completed LICENSE AND CERTIFICATE OF DECLARATION OF MARRIAGE must be returned within 10 days of completion by either of

the parties declaring the marriage to be registered by the local registrar of marriages (County Recorder) of the county where the license was

issued at the address in box 25G. It can be mailed or delivered in person.

PRIVACY NOTIFICATION

Civil Code Section 1798 et seq. requires each state agency to provide this notice to individuals completing this form. The information is being

requested by: State of California, Department of Public Health, Office of Vital Records, MS 5103, P.O. Box 997410, Sacramento, CA 95899-

7410, Telephone (916) 445-2684.

The information requested on this certificate is authorized and required by Division 102 of the Health and Safety Code, and related provisions

within the Civil Code, Code of Civil Procedure, Family Code, and Government Code.

The completion of all items requested on this form is mandatory. Health and Safety Code Section 103775 provides that, “Every person,

except a parent informant for a certificate of live birth, who is responsible for supplying information who refuses or fails to furnish correctly any

information in his or her possession which is required by this division, or furnishes false information affecting any certificate or record required

by this division, is guilty of a misdemeanor.”

The principal purpose for this record is:

To establish a permanent record that is legally recognized as prima facie evidence of the facts stated therein for each marriage

occurring in the State of California.

To provide individuals with certified copies from the records to serve their personal needs, such as securing passports and applying

for social security or death benefits.

To provide information to health authorities and other qualified persons with a valid educational or scientific interest, for demographic

and epidemiological studies for health and social purposes.

This information is also provided to the National Center for Health Statistics for compiling national statistical reports.

This record shall be open for examination during regularly scheduled office hours, except when access is specifically prohibited by statute or

regulations.

For Official Use Only

STATE OF CALIFORNIA, DEPARTMENT OF PUBLIC HEALTH, OFFICE OF VITAL RECORDS

VS-116 (01/01/2010)

License And Certificate Of Marriage Template Page 2

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