Fillable Printable Application for Marriage License or Certificate - Texas

Application for Marriage License or Certificate - Texas

APPLICATION FOR MARRIAGE LICENSE,

______________________________

COUNTY, TEXAS

The form and content of this application is prescribed by section 2.004 of the Texas Family Code.

WARNING: IT IS A FELONY TO FALSIFY INFORMATION ON THIS DOCUMENT. THE PENALTY FOR KNOWINGLY MAKING A FALSE STATEMENT ON THIS

FORM OR FOR SIGNING A FORM WHICH CONTAINS A FALSE STATEMENT IS 2 TO 10 YEARS IMPRISONMENT AND A FINE OF UP TO $10,000. (HEALTH AND

SAFETY CODE, CHAPTER 195, SEC. 195.003)

Applicant One

First Name

Middle Name Current Last Name Suffix

Woman’s Maiden Name (If Applicable)

Telephone Number

Street Address

City State Zip

Date of Birth

Place of Birth (including city, county and state) Social Security Number

I have not been divorced within the last 30 days

□

TRUE

□

FALSE

I am not presently married

□

TRUE

□

FALSE

I am not presently delinquent in the payment of court ordered child support.

□

TRUE

□

FALSE

The other applicant is not presently married

□

TRUE

□

FALSE

I am not related to the other applicant as:

□

TRUE

□

FALSE

an ancestor or descendant, by blood or adoption;

a brother or sister, of the whole or half blood or by adoption;

a parent's brother or sister, of the whole or half blood or by

adoption;

a son or daughter of a brother or sister, of the whole or half blood or

by adoption;

a current or former stepchild or stepparent; or

a son or daughter of a parent's brother or sister, of the whole or half

blood or by adoption;

□

I wish to make a voluntary contribution of $5.00 to promote healthy early childhood by supporting the Texas Home Visitation Program administered by the Office of Early

Childhood Coordination of Health and Human Services [Texas Family Code 2.004(13)].

I solemnly swear (or affirm) that the information I have given in this application is correct _____________________________________________

Applicant

’

s Signature and Date Signed

Applicant Two

First Name

Middle Name Current Last Name Suffix

Woman’s Maiden Name (If Applicable)

Telephone Number

Street Address

City State Zip

Date of Birth

Place of Birth (including city, county and state) Social Security Number

I have not been divorced within the last 30 days

□

TRUE

□

FALSE

I am not presently married

□

TRUE

□

FALSE

I am not presently delinquent in the payment of court ordered child support.

□

TRUE

□

FALSE

The other applicant is not presently married

□

TRUE

□

FALSE

I am not related to the other applicant as:

□

TRUE

□

FALSE

an ancestor or descendant, by blood or adoption;

a brother or sister, of the whole or half blood or by adoption;

a parent's brother or sister, of the whole or half blood or by

adoption;

a son or daughter of a brother or sister, of the whole or half blood or

by adoption;

a current or former stepchild or stepparent; or

a son or daughter of a parent's brother or sister, of the whole or half

blood or by adoption;

□

I wish to make a voluntary contribution of $5.00 to promote healthy early childhood by supporting the Texas Home Visitation Program administered by the Office of Early

Childhood Coordination of Health and Human Services [Texas Family Code 2.004(13)].

I solemnly swear (or affirm) that the information I have given in this application is correct _____________________________________________

Applicant

’

s Signature and Date Signed

Mail Executed License To (Street/P.O. Box, City, State, Zip)________________________________________________________________________

For County Clerk Office Use Only

Subscribed and sworn to before me, or I certified that the applicant did not appear personally but the prerequisites for the license have been fulfilled by

§2.007 of the Texas Family Code on ________________________, 20_____ at _______________am/pm

_____________________________ County Clerk ___________________County, Texas. Ceremony Performed By_____________________________

By ___________________________________ Deputy Date of Marriage_______________ County/Place of Marriage________________________

Applicant One Identification Type (ID & Age)___________________________________ License Number _______________________

Applicant Two Identification Type (ID & Age)___________________________________ Volume _______________ Page ______________

VS-180 Rev. 06/2015