Application For Civil Marriage License
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1Application for Civil Marriage License
Full Price
License valid for six months from date of issuance – NO REFUNDS
Reduced
STATE OF MINNESOTA, COUNTY OF SHERBURNE
FILE#
C
N
(F
)
(M
)
(L
)
S
S
N
.
OMPLETE
AME
IRST
IDDLE
AST
OCIAL
ECURITY
O
Current
Name
A
GE
B
B
G
I
I
IRTHDATE
IRTHPLACE
ENDER
CERTIFY THAT
DO NOT HAVE A SOCIAL SECRUITY
M
F
.
NUMBER
S
R
.
IGNATURE
EQUIRED
A
(
&
)
DDRESS
NUMBER
STREET
X
C
C
S
ZIP
ITY
OUNTY
TATE
N
.
H
C
M
T
D
T
(
/
/
)
W
T
(
: C
)
C
(
: D
, C
)
O
OF PREVIOUS
OW LAST
IVIL
ARRIAGE
ERMINATED
ATE
ERMINATED
MM
DD
YYYY
HERE
ERMINATED
IE
OUNTY
OURT
IE
ISTRICT
IRCUIT
C
M
IVIL
ARRIAGES
(
,
,
)
DEATH
DIVORCE
ANNULMENT
P
M
N
(F
)
(M
)
(L
)
REVIOUS
ARRIED
AME
IRST
IDDLE
AST
C
N
(F
)
(M
)
(L
)
S
S
N
.
OMPLETE
AME
IRST
IDDLE
AST
OCIAL
ECURITY
O
Current
Name
A
GE
B
B
G
I
I
IRTHDATE
IRTHPLACE
ENDER
CERTIFY THAT
DO NOT HAVE A SOCIAL SECRUITY
.
NUMBER
M
F
S
R
.
IGNATURE
EQUIRED
A
(
&
)
DDRESS
NUMBER
STREET
X
C
C
S
ZIP
ITY
OUNTY
TATE
N
.
H
L
C
M
T
D
T
(
/
/
)
W
T
(
: C
)
C
(
: D
, C
)
O
OF PREVIOUS
OW
AST
IVIL
ARRIAGE
ERMINATED
ATE
ERMINATED
MM
DD
YYYY
HERE
ERMINATED
IE
OUNTY
OURT
IE
ISTRICT
IRCUIT
C
M
(
,
,
)
IVIL
ARRIAGES
DEATH
DIVORCE
ANNULMENT
P
M
N
(F
)
(M
)
(L
)
REVIOUS
ARRIED
AME
IRST
IDDLE
AST
N
:
I
U
18 Y
A
,
AME
F EITHER OF THE PARTIES IS
NDER
EARS OF
GE
GIVE THE
/
.
NAME AND ADDRESS OF HIS
HER PARENTS OR GUARDIAN
A
:
DDRESS
D
?
OES BLOOD OR ADOPTION RELATE THE PARITES TO EACH OTHER
I
Y
, W
?
F
ES
HAT IS THE RELATIONSHIP
YES
NO
#1 (
)
(M
)
(L
)
APPLICANT
FIRST
IDDLE
AST
G
IVE THE NAMES THE PARTIES WILL HAVE
:
A
C
M
FTER
IVIL
ARRIAGE
#2 (
)
(M
)
(L
)
APPLICANT
FIRST
IDDLE
AST
A
(N
& S
)
DDRESS
UMBER
TREET
A
DDRESS THE PARTIES WILL HAVE
:
A
C
M
FTER
IVIL
ARRIAGE
C
S
ZIP
ITY
TATE
(W
)
ILL APPEAR ON MARRIAGE CERTIFICATE AND WILL BE MAILED TO
D
OES ONE OR BOTH OF THE PARTIES HAVE A FELONY CONVICTION
Y
N
#1:
ES
O
I
, J
:
APPLICANT
F YES
URISDICTION
A
1, 2000
FOR A CRIME COMMITTED ON OR AFTER
UGUST
UNDER
M
INNESOTA LAW OR THE LAW OF ANOTHER STATE OR FEDERAL
Y
N
#2:
ES
O
I
, J
:
APPLICANT
F YES
URISDICTION
?
JURISDICTION
PLEASE STOP HERE
N
: a party who has a felony conviction for a crime committed on or after August 1, 2000 under Minnesota law or the law of another state or federal jurisdiction may not use a different name after civil
OTICE
marriage except as authorized by Minnesota statute 259.13, and doing so is a gross misdemeanor.
T
:
ENNESSEN 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 it on the civil marriage license application (title 42, US Code Sec 666 (a) (13) (a) MN Statues, section 144.223), and MN
Statues, sec 517.08 subd 1a (1997), Your social security number is reported to the MN 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.
We declare upon oath that all of the above answers and statements of facts are true and correct; that neither of us has a spouse living and that neither of us is a mentally deficient person committed to the
guardianship or conservatorship of the Commissioner of Human Services.
SIGNATURE X ________________________________________________________
PHONE NUMBER (________)_________________________________________
SIGNATURE X ________________________________________________________
PHONE NUMBER (________) ________________________________________
SUBSCRIBED AND SWORN to before me this ________ day of ______________________________________, 20 _________ MICHELLE ASHE, SHERBURNE COUNTY RECORDER
BY: _________________________________________________, DEPUTY
DATE ISSUED:
ISSUED VIA:
PAYMENT
TENTATIVE CIVIL MARRIAGE
ACTUAL DATE OF CIVIL
PLACE OF CIVIL MARRIAGE:
CEREMONY
TYPE:
DATE:
MARRIAGE:
TYPE:
MAIL #1 / #2
OFFICE
USE ONLY
CASH
RELIGIOUS
PICK UP
CHECK
CIVIL
Rev 7/31/2013
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