Fillable Printable Application for License and Certificate of Marriage - New Jersey

Application for License and Certificate of Marriage - New Jersey

REG-77

AUG 14

New Jersey Department of Health

APPLICATION FOR LICENSE

MARRIAGE REMARRIAGE CIVIL UNION REAFFIRM ATION OF CIVIL UNION

(PLEASE PRINT OR TYPE)

DECLARATION OF APP LICANT A

(Giving false information constitutes perjury.)

DECLARATION OF APPLICANT B

(Giving false information constitutes perjury.)

1.Name (First, Middle, Last) (List name given at birth or on birth certificate)

Street Addr ess (Curre nt Legal Residence)(See Note 1)

County

Street Addr ess (Curre nt Legal Residence)(See Note 1)

County

Municipality of Residence (See Note 4)

State

Zip Code

Municipality of Residence (See Note 4)

State

Zip Code

1a.Current Name (if diff erent)

2.Date of Birth

1a.Current Name (if diff erent)

2.Date of Birth

3.Birthplace

4.Sex

5.Age(See Note 2)

3.Birthplace

4.Sex

5.Age(See Note 2)

6.Domestic Status (at this time) (See Not es 3 and 5)6.Domestic Status (at this time) (See Not es 3 and 5)

DatePlaceDatePlace

SingleSingle

Widowed

Divorced

Annulled

Current Domestic

Partner

Current Domestic

Partner

Former Domestic

Partner

Former Domestic

Partner

Current Civil

Union Partner

Current Civil

Union Partner

Former Civil

Union Partner

Former Civil

Union Partner

For Remarriage to the same spouse, or Reaffirmation of Civil Union to the

same partne r, ente r da te and place of orig ina l ceremo ny:

For Remarriage to the same spouse, or Reaffirmation of Civil Union to the

same partne r, ente r da te and place of orig ina l ceremo ny:

DatePlaceDatePlace

Marriage

Civil Union

Marriage

Civil Union

7a.Enter number of times ever

Married (if applicable):

7b.Name of Most Recent Spouse (if any)

(List name gi ve n at bir t h or on birth certifi cate):

7a.Enter number of times ever

Married (if applicable):

7b.Name of Most Recent Spouse (if any)

(List name gi ve n at bir t h or on birth certifi cate):

8a.Enter number of times ever

in a Civil Union

(if applicable):

8b.Name of Most Recent Civil Union Partner (if any)

(List name gi ve n at bir t h or on birth certifi cate):

8a.Enter number of times ever

in a Civil Union

(if applicable):

8b.Name of Most Recent Civil Union Partner (if any)

(List name gi ve n at bir t h or on birth certifi cate):

9a. Parent’s Full Name at Birth

9b. Birthplace

9a. Parent’s Full Name at Birth

9b. Birthplace

10a. Parent’s Full Name at Birth

10b. Birthplace

10a. Parent’s Full Name at Birth

10b. Birthplace

11. Are you related to Applicant B?YesNo

If “YES,” how?

11. Are you related to Applicant A?YesNo

If “YES,” how?

INFORMATION TO BE COMPLETED BYEITHERAPPLICANT

12.In which Incorporated Municipality in New Jersey do you intend for the ceremony

to be performe d? (See Note 4)

13Intended Date of Ceremony

14.Telephone Number where either

applicant can now be reached:

15.Name and mailing address of person who is to perform the ceremony:

16.Mailing Address where you may be reached after the ceremony:

(See Notes on Page 2)Continue with Declaration o f Id entifying Witness and Oath.

UPON CO MPLETION, APPLICATION IS TO BE RETAINED AS A PERMANENT RECORD.

DECLARATION OF IDENTIFYING WITNE SS

(Giving false information constitutes perjury)

1.Name (First, Middle, Last):

Mailing Address (Street/PO Box):

City:

State:

Zip Code:

2.Have the applica nts correctl y stated their ages and usual resid ences?YesNo

3.Did the applicants make you aware of any legal impedime nt to their

marriage / remarriage / civil u nio n / reaffirmation of civil union?

YesNo

If “Yes, “ explain:

OATH OR AFFIRMATION OF APPLICANTS AND IDENTIFYING WITNESS

NOTE TO REGISTRAR - Applicants and witness should be told that taking a false oath constitutes perjury, which is punishable by a

maximum fine of $7,500.00. In any case where application is made by only one applicant to begin the waiting period, the same

identifying witness must return when the second applicant completes the application. In such a case the same witness must sign

once again on the line below that on w hich he/she signed when appearing with the first applicant.

We, who have hereunder signed our names, do solemnly swear (or affirm) that we are not currently ruled mentally

incompetent; the answers given by us in this application for a marriage, remarriage, civil union, or reaffirmation of civil union

license are true, full and perfect answers to each an d all of said questions.

Signature of Applica nt A:Date:

Signature of Applica nt B:Date:

Signature of Witness:Date:

Second Signature of

Witness (if necessary):

Date:

Sworn (or affirmed) and subscri be d before me at

thisday of, 20atAMPM

Signature of Registrar:

REGISTRAR - DO NOT insert place and date of ceremony or file the application until either the completed certificate or copy

thereof is sent to you. Follow-up on all licenses for completion.

License Number:Date of Issue:

Ceremony Performed in (City, Borough, Twp.):

Date of Ceremony:

NOTE 1. This is the permanent home and principal establishment to

which, when absent, the applicant intends to return.

NOTE 2. Written consent of both parents is required for the marriage

or civil union of any person under eighteen years of age. In addition,

if any person is under sixteen, the consent of the parents must be

approved in writing by a judge of the Superior Court, Chancery

Division, Family Part. Consent of parents is required for the

remarriage or reaffirmation of civil union of a minor previously married

or joined in a civil union to the same partner in another state.

NOTE 3. When a remarriage or reaffirmation of civil union license is

requested, indicate in Question 6 that the parties are already married

or joined in a civil union. It is required that proof of the previous

marriage or civil union be submitted to you. Common law marriages,

which were legal prior to December 1, 1939, must be established by

affidavit showing the place and date of the common law marriage

contract. The place and date of the previous marriage or civil union

should be stated on both the application and the license. The

seventy-two hour waiting period is waived. Consent of parents is

required for the remarriage or reaffirmation of a civil union of a minor

previously joined in a marriage or civil union to the same partner in

another state.

NOTE 4. Municipality of residence is the municipality where applicant

physically resides, not the mailing address.

If both applicants are

nonresidents of New Jersey, the application must be made in the

municipality where the ceremony will be performed. Registrar should

mark the license accordingly.

NOTE 5. The Registrar’s review of a divorce decree, dissolution of

Civil Union, or termination of Domestic Partnership, submitted with

this application, in no way implies the validity of the submitted

document. Such determination can only be made by a court of law.

APPLICANTS MUST PROVIDE THEIR SOCIAL SECURITY NUMBERS (N. J. S. 37:1-17)

Social Security Number of Applicant ASocial Security Number of Applicant B

Social Security Numbers shall be kept confidential and may only be released for child support purposes and

this document shall not be considered a public record pursuant to P. L. 1963, C.73 (C.47:1A-1 et seq.).