Form Prescribed By Indiana State Department of Health under

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Form Prescribed By Indiana State Department of Health under Powered By Docstoc
					                          APPLICATION FOR MARRIAGE                                                                                                                                      Number
                          LICENSE
                          State Form 53394 (10-07)                                                                                                                                      File
                          Indian State Department of Health
                          Prescribed under authority of IC 31-11-4-4                                                             County
                                                                                                                                                                                                          Date of Application (month, day, year)

                                               MALE APPLICANT                                                                                                                     FEMALE APPLICANT
                                                                                                               Yes        No                                                                                                                        Yes    No
    1. Are you now or have you ever been adjudged to be of unsound mind?                                                            1. Are you now or have you ever been adjudged to be of unsound mind?                                                
           If yes, has the adjudication been removed?                                                                                      If yes, has the adjudication been removed?                                                                   
    2. Are you related to the co-applicant closer than second cousin?                                                               2. Are you related to the co-applicant closer than second cousin?                                                   
           If yes, are you first cousins and over age 65?                                                                                  If yes, are you first cousins and over age 65?                                                               
    3. Are you now under the influence of an alcoholic beverage?                                                                    3. Are you now under the influence of an alcoholic beverage?                                                        
    4. Are you now under the influence of a narcotic drug?                                                                          4. Are you now under the influence of a narcotic drug?                                                              
    Name                                                                                                                              Name
                 First                               Middle                                 Last                                                     First                                Middle                                 Last

    Date of                                                                                                                           Date of Birth
    Birth                     Month                           Day                    Year                                                                          Month                           Day                    Year

    Date of Birth                  Birth Certificate              Valid Operator License / ID Card                                  Date of Birth              Birth Certificate                 Valid Operator License / ID Card
    Verified By                    Other (specify)                                                                                   Verified By                Other (specify)

    Place of Birth (State or Foreign Country)                                                                                         Place of Birth (State or Foreign Country)
    Residence                                                                                                                         Residence


                              Street/City/State/Zip or Street/City/Foreign Country                                                                                 Street/City/State/Zip or Street/City/Foreign Country

    Dependent Children (list full names of each)                                                                                      Dependent Children (list full names of each)




    Father’s Full Name                                                                                                                Father’s Full Name
    (if adopted, list adoptive father                                                                                                 (if adopted, list adoptive father
    only)                                                                                                                             only)



    Residence of                                                                                                                      Residence of
    Father (Last Known.                                                                                                               Father (Last Known.
    if deceased, so state)                                                                                                            If deceased, so state)
                                          Street/City/State/Zip or Street/City/Foreign Country                                                                               Street/City/State/Zip or Street/City/Foreign Country

    Birthplace of Father                                                                                                              Birthplace of Father
    (state or foreign country)                                                                                                        (state or foreign country)

    Mother’s Full Maiden                                                                                                              Mother’s Full Maiden
    Name (if adopted, list adoptive                                                                                                   Name (if adopted, list adoptive
    mother only)                                                                                                                      mother only)



    Residence of                                                                                                                      Residence of
    Mother (Last Known.                                                                                                               Mother (Last Known.
    if deceased, so state)                                                                                                            if deceased, so state)
                                          Street/City/State/Zip or Street/City/Foreign Country                                                                               Street/City/State/Zip or Street/City/Foreign Country

    Birthplace of Mother                                                                                                              Birthplace of Mother
    (state or foreign country)                                                                                                        (state or foreign country)


    Consent of Parent(s) or Guardian(s) (if                              applicant is under 18)                                       Consent of Parent(s) or Guardian(s) (if applicant is under 18)
       I (we), the parent(s) of this applicant, hereby give consent for this marriage. (If                                               I (we), the parent(s) of this applicant, hereby give consent for this marriage. (If
       only one parent signs, state facts which make consent of the other parent unnecessary)                                            only one parent signs, state facts which make consent of the other parent unnecessary )
    Signature of Parent/Guardian                                                                                                      Signature of Parent/Guardian
    Signature of Parent/Guardian                                                                                                      Signature of Parent/Guardian

 Subscribed and sworn to before me this                                          day of                     , 20                    Subscribed and sworn to before me this                                            day of                       , 20

                                                 Clerk of the                                             Circuit Court                                                              Clerk of the                                              Circuit Court

Acknowledgements: I acknowledge that I have received information regarding dangerous communicable diseases that are sexually transmitted and a list
of the test sites for the virus that causes AIDS (Acquired Immune Deficiency Syndrome).
Signature of applicant                                                                                                                   Signature of applicant
Date (month, day, year)                                                                                                                  Date (month, day, year)
              The above applicant has objected to verifying by oath or affirmation or signature to                                                    The above applicant has objected to verifying by oath or affirmation or signature to the
             the above acknowledgment because of religious beliefs.                                                                                   above acknowledgment because of religious beliefs.

Affirmation: I swear/affirm that the information given in this application is true and correct and have been advised of IC31-11-11-1 as follows:
IC 31-11-11-1. False information in marriage license application. A person who knowingly furnishes false information to a clerk of the circuit court when the person
applies for a marriage license under IC 31-11-4 commits a Class D felony.

Signature of applicant                                                                             Date                                 Signature of applicant                                                                          Date

     Subscribed and sworn to before me this                                           day of                  ,20                          Subscribed and sworn to before me this                                            day of                  ,20



                                                  Clerk of the                                       Circuit Court                                                             Clerk of the                                                        Circuit Court

Court Order: A marriage license having been refused to the above named parties, the                                       County                                   Court,
by written order issued                       and filed in                          authorizes and directs the issuance of a marriage license to the above named parties.

                                                                                       Return of Marriage License and Marriage Certificate
I certify that there was filed in my office a marriage license dated                                                   authorizing the marriage of the individuals listed below. I further certify that the following marriage certificate was
 filed in my office.
I,                                                                          (name), certify that on                                 (date), at                                                     in                                                County, Indiana,

                                                                    of                                                 County,                                                   (state), and                                                                   of

                                              County,                                                     (state) were married by me as authorized under a marriage license that was issued by the Clerk of the Circuit Court of

                                              County, Indiana, dated                                               .     Signed by:                                                                     Official Designation:

Filed and recorded in accordance with the laws of the State of Indiana on                                                                             (date).

Signed                                                                                                , Clerk of the                                                              Circuit Court.
:
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