CARTRIDGE__________
IMAGE __________
Hennepin County
SUPPLEMENTAL TO APPLICATION FOR MARRIAGE LICENSE
FOR PARTY NOT APPEARING
If one of the parties cannot appear in person at the Local Registrar’s Office at the time of application for marriage, the applicant appearing will
complete the full application supplying all of the information for both parties. This supplemental application must be completed by the non‐
appearing marriage applicant.
Notice: a party who has a felony conviction for a crime committed under Minnesota law or the law of another state or federal jurisdiction may not
use a different name after marriage except as authorized by Minnesota statute 259.13, and doing so is a gross misdemeanor.
Full Legal Name:__________________________________________________________________________________________________________
Name after Marriage:______________________________________________________________ _______________________________________
I hereby swear or affirm that I have either committed no felony crimes under any Law, or if I have committed a felony crime, that I have
complied with the notice requirements as set forth in Minnesota Statutes. I understand that a person who has a felony conviction who
does not comply with Minnesota Statute 259.13 and uses a different name after marriage than what was used before is guilty of a gross
misdemeanor.
If NOT applicable, please check here: _____________Signature_____________________________
OR
If applicable, Date Prosecutor Served: ___________ Signature:_____________________________
Attach Affidavit of Service
Certification to accuracy of Marriage Application
_____My social security number is: _________________________________________
_____I certify that I do not have a social security number.
Tennessen warning for the collection of social security numbers: If you have a social security number you are required by federal and state law
to put provide it per (title 42 US Code Sec 666(a) (13) (a) MN statutes section 144.223, and MN statutes, sec 517.08 subd 1a. Your social security
number is reported to the Minnesota Department of Health and will be kept private. If necessary, your social security number may be used to
help obtain financial support of your child.
I hereby certify that I am the party listed as an applicant on this marriage application. I was unable to appear in person to make this application. I
have reviewed the information supplied by the party appearing and certify to the accuracy of the information.
Print Form
Clear Form
_________________________________________
Signature (must be notarized)
Subscribed and sworn before me this day __________ of , 20____
____________________________________________________
Notary
My Commission expires: ________________________________(seal)
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