Vital Records Marriage/divorce Application Form
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2Vital Records Marriage/Divorce Application
A photocopy of a current government, school or employer photo identification of the applicant must be
submitted with all requests. Applications without proper identification will be returned unprocessed.
Name of applicant:_____________________________________________________________ Day phone number:______________________
Address: _____________________________________________________________________________________________________________
City:______________________________________________ State:_______________________________ Zip code:_______________________
E-mail address: ________________________________________________________________________________________________________
Note: Mail from Vital Records will not be forwarded by the USPS.
Address certificate to be mailed to if different than applicant’s address:
Name: _______________________________________________________________________________________________________________
Address: _____________________________________________________________________________________________________________
City: ___________________________________________________________ State: _________________________ Zip code: ______________
Your relationship to person named on the certificate? (Check one - will be used to determine entitlement)
____Self
____ Adult child ____ Present or former spouse
____ Legal representative (for whom?)__________________________________
By signing this application, I understand that making a false application for a vital record is a felony under state law.
Signature of applicant: __________________________________________________________________________________________________
MARRIAGE
Name of bride:_________________________________________________________________________________________________________
First
Middle
Last Suffix
Other married surnames used by bride: _____________________________________________________________________________________
Name of groom: _______________________________________________________________________________________________________
First
Middle
Last Suffix
Date of marriage: _________________________ County where marriage license obtained: ____________________________________________
South Carolina
Specify the number and type of certification(s) requested:
_____Marriage long form ($12) _____ Additional long ($3 each)
_____Statement of marriage (names, date, and county only -$12) _____ Additional statements ($3 each)
Total fees submitted: ____________________________________
DIVORCE/ANNULMENT
Name of wife: _________________________________________________________________________________________________________
First
Middle
Last
Suffix
Other married surnames used by wife: _____________________________________________________________________________________
Name of husband: _____________________________________________________________________________________________________
First
Middle
Last Suffix
Date of divorce or annulment: _____________________________ County where divorce obtained: ___________________________________
South Carolina
Specify the number and type of certification(s) requested:
____Divorce long form ($12)
____ Additional divorce long ($3 each)
____Statement of divorce ($12)
____ Additional statements ($3 each)
Total fees submitted: ___________________________________
Send completed application/photocopy of identification to:
SC DHEC – Vital Records
2600 Bull Street, Columbia, SC 29201
OFFICE USE ONLY
SFN:
DCN:
SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
DHEC 0639 (09/2013)
See back for Instructions and Information
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