Fillable Printable Application for License and Certificate of Marriage - California

Application for License and Certificate of Marriage - California

STATE OF CALIFORNIA, DEPARTMENT OF PUBLIC HEALTH, OFFICE OF VITAL RECORDSVS-117Be (01/2010)

APPLICATION FOR LICENSE AND CERTIFICATE OF MARRIAGE

PLEASE READ BEFORE COMPLETING APPLICATION

When you sign the marriage application form, you are stating under penalty of perjury that the information you have provided is true and

correct, that you arecurrently anunmarried couple,and that there is no legal objection to the marriage.

If you are usinga regular public marriage license, you may be married anywhere in California. Ifyou are using a confidential marriage license,

you must be married in the same county that issues the license. Check the licenseto see what the requirements are for witnesses and

solemnization.

Marriagelicenses are valid for 90 days from the date of issuance. You must be married on or after theissuance date, and on or before the

expiration date of the license. Licenses not used within this timeframe are void.

The appropriate fee may be paidincash or by check, payable tothe county clerk.

No refunds are given for marriage licenses purchasedin error.

Please check the type of marriage license you would like to apply for:

License and Certificate of Marriage (VS 117)— This isthe standard type of marriage license. This type of marriage license

requires the signatureof at least one witness and one person solemnizing the marriage.

License and Certificate of Marriage for Denominations Not Having Clergy (VS 115)—This type of license is used for the

recording of marriages for members of religious societies or denominations thatdo not have clergyfor the purpose of solemnizing a

marriage.

License and Certificate of Declaration of Marriage (VS 116)— This type of licenseis usedfor the recording ofa marriage that

was licensed and occurred over one year ago; however, no official record exists.

Confidential License and Certificate of Marriage (VS 123)— Confidential marriage licenses may onlybe issued to unmarried

parties who are at least 18 yearsold and have been living together as spouses. Since the confidential marriage license requires the

signature of a marriage officiant, they are not available to members of religious denominations not having clergy. Certified copies of

the marriagelicense and certificate may only be issued to the couple. Confidential marriage licenses may not be available in all

counties. The signatures of the parties in fields 23 and 24affirm that they meet therequirements to receive a confidential marriage

license.

INFORMATION REGARDING THE NAME EQUALITY ACTOF 2007

The Name Equality Act of 2007 (AB 102, Chapter 567, Statutesof 2007, amended by AB 1143, Chapter 412, Statutes of 2009) allows oneor

both applicants to a California marriage to elect to change the middle and/or last names by which each party wishes tobe known after they are

marriedby entering the new name in fields 29A thru 30C, as applicable, on the marriage license application. This must be done at thetime

the applicants areapplying for the marriage license.

Each party to the marriage mayadopt any of the following last names (Family Code Section 306.5(b)(2)):

Current last name of the other spouse

Last name of either spouse given at birth

A name combining into asingle last name all ora segment of the current last name orthelast name of either spouse given at birth

A hyphenated combination of last names

Each part to the marriage mayadopt any of the following middle names (Family Code Section 306.5 (b)(3):

Current last name of either spouse

The last name of eitherspouse given at birth

A hyphenated combination of the current middle nameand thecurrent last name of the person or spouse

NOTE: Parties to the marriage may notchange theirfirst name onthe marriage license.Parties to the marriage may not add or amendthis

information after the marriage license is issued unless it is a clerical error and theamendment is signed by the county clerkand one of the

parties to the marriage.

Parties to the marriage arenotrequiredto change their name, nor, arethey required to have thesame name.

If one orbothparties do not wish to identify a new name on the marriage license,the fields on the marriage license will be

completed using two single dashes. You may not change the information on the marriage license after it has been issuedby the

County Clerk.

The marriage certificate is used by multiple local, state, federal and private agencies, each of which have different requirements regarding

what documents are acceptable to change your name on their records following marriage. It is recommended that you contact these agencies

to verify their requirements prior to applying for your marriagelicense.

County Clerk staff cannot provide you information on how to complete the marriage license application as it relates to the entryof a new name

or retention of your former name on the marriage licenseapplication. For your protection, if youhaveany questions regarding whether you

should or should not list your new name on the marriage license application, and/orhow the Name Equality Act of 2007 mayaffect you, please

consult with a private attorney prior to applying for your marriagelicense.

STATE OF CALIFORNIA, DEPARTMENT OF PUBLIC HEALTH, OFFICE OF VITAL RECORDSVS-117Be (01/2010)

APPLICATION FOR LICENSE AND CERTIFICATE OF MARRIAGE

MUST BE LEGIBLE

1A. FIRST NAME

1B. MIDDLE

1C. CURRENT LAST

1D. LAST NAME AT BIRTH (IF DIFFERENTTHAN1C)

2. DATE OF BIRTH (MM/DD/CCYY)

3. STATE/COUNTRY OF BIRTH

4. # PREV. MARRIAGES / SRDP

5A. LAST MARRIAGE / SRDP ENDED BY:

DEATH DISSO ANNULMENT TERM SRDPN/A

5B. DATE ENDED (MM/DD/CCYY)

6. ADDRESS

7. CITY

8. STATE / COUNTRY

9. ZIP CODE

10A. FULL BIRTH NAMEOF FATHER / PARENT

10B. STATE OF BIRTH (IF OUTSIDE U.S., ENTERCOUNTRY)

11A. FULL BIRTH NAMEOF MOTHER / PARENT

11B. STATE OF BIRTH (IF OUTSIDE U.S., ENTERCOUNTRY)

12A.FIRST NAME

12B. MIDDLE

12C. CURRENT LAST

12D. LASTNAMEAT BIRTH (IF DIFFERENT THAN12C)

13. DATE OF BIRTH(MM/DD/CCYY)

14. STATE/COUNTRY OF BIRTH

15. # PREV. MARRIAGES / SRDP

16A. LAST MARRIAGE / SRDP ENDED BY:

DEATH DISSO ANNULMENTTERM SRDP N/A

16B. DATE ENDED (MM/DD/CCYY)

17. ADDRESS

18. CITY

19. STATE / COUNTRY

20. ZIP CODE

21A. FULL BIRTH NAMEOF FATHER / PARENT

21B. STATE OF BIRTH (IF OUTSIDE U.S., ENTERCOUNTRY)

22A. FULL BIRTH NAMEOF MOTHER / PARENT

22B. STATE OF BIRTH (IF OUTSIDE U.S., ENTER COUNTRY)

WE, THE UNDERSIGNED DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT WE ARE UNMARRIED AND THAT THE FOREGOING INFORMATION IS TRUE AND CORRECT

TO THE BEST OF OUR KNOWLEDGE AND BELIEF. WE FURTHER DECLARE THAT NO LEGAL OBJECTION TO THE MARRIAGE NOR TO THE ISSUANCE OFA LICENSE IS KNOWN TO US. WE ACKNOWLEDGE RECEIPT

OF THE INFORMATION REQUIRED BY FAMILY CODE SECTION 358 AND HEREBY APPLY FOR A LICENSE ANDCERTIFICATEOF MARRIAGE.

23.SIGNATURE OF PERSON LISTED IN FIELDS 1A-1D



24. SIGNATURE OF PERSON LISTED IN FIELDS 12A-12D



25. ISSUE DATE

26. EXPIRES AFTER (MM/DD/CCYY)

27. MARRIAGE LICENSENUMBER

28. CLERK ISSUING LICENSE

NEW MIDDLE AND LAST NAME OF PERSON LISTED IN 1A-1D (IF ANY) FOR USE UPON SOLEMNIZATION OF THE MARRIAGE

29A. FIRST– MUST BE SAME AS 1A 29B. MIDDLE 29C. LAST

NEW MIDDLE AND LAST NAME OF PERSON LISTED IN 12A-12D (IF ANY) FOR USE UPON SOLEMNIZATION OF THE MARRIAGE

30A. FIRST – MUST BE SAME AS 12A 30B. MIDDLE 30C. LAST

 Groom  Bride

FIRST PERSON DATA

PERSONAL DATA

 Groom  Bride

SECOND PERSON DATA

AFFIDAVIT

NEW NAMES

IF ANY