Marriage Certificate Request

          NON-REFUNDABLE SEARCH FEE            Proof of identity of applicant:                      STATE PERSONNEL USE ONLY ________
                                               Applicant must provide one of these:
         Marriage Certificate                      ❒   Driver’s License                             CERT# _______________ # of copies_____
                                                   ❒   Passport
Full Maiden Name of Bride/Spouse:
                                                   ❒   Government issued picture I.D.               AMOUNT PAID
                                               OR two of these:
Full Name of Groom/Spouse:                         ❒   Utility bills                                CASH ______ CHECK#______ CC_______
                                                   ❒   Bank statements
Date of Marriage:                                  ❒   Vehicle registration                         ID Shown:
Place license issued:                              ❒   Income tax return

Applicant Name:                                    ❒   Personal Check w/ address
                                                                                                    ID #:
                                                   ❒   A previously issued vital record
                                                   ❒   Letter from government agency requesting
Applicant Address:                                                                                  Expires:
                                                       record (DHHS, WIC)
                                                   ❒   Department of Corrections I.D. card
                                                   ❒   Social Security Card                         Notes:
Indicate your Relationship to the person on        ❒   DD 214
requested record below:                            ❒   Hospital; birth worksheet
             ❒ Self/Spouse                         ❒   License/rental agreement

❒ Parent                              ❒   Pay stub

❒ Guardian ❒ W-2

❒ Voter Registration card

❒ Descendant

❒ Disability award from SSA

❒ Attorney of person on record

❒ Other _________________

❒ Genealogist ID # ____________ Establishing eligibility to acquire record:

❒ Related applicants must provide proof of lineage. By signing below, I swear/affirm that the ❒ Domestic Partners must provide proof of information above is true and correct. registration of domestic partnership

Applicant Signature: ❒ Attorneys must provide a signed, notarized release from family

❒ Genealogists must provide a state-issued Today’s Date: st card $15 for 1 copy, $6 for each additional copy

❒ Do not retain copies of proof provided or NON-REFUNDABLE SEARCH FEE note any specific numbers incountermarform.doc R 09/2018