Marriage Worksheet - State Of Nebraska - Department Of Health And Human Services Finance And Support

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State of Nebraska – Department of Health and Human Services Finance and Support – VITAL RECORDS

MARRIAGE WORKSHEET

*License is valid ONLY in the state of Nebraska*

1. Groom/Applicant 1 - Full Name (First, Middle, Last, Suffix)

NAME AT BIRTH (if different)

2. AGE

3a. COUNTRY

3b. STATE

3c. COUNTY

3d. CITY, TOWN OR LOCATION

3e. RESIDENCE – Street and Number

3f. ZIP CODE

4. BIRTHPLACE (City and State or Foreign Country)

5. DATE OF BIRTH (Mo., Day, Yr.)

6a. FATHER’S – Full Name (First, Middle, Last, Suffix)

6b. BIRTHPLACE (City and State or Foreign Country)

7a. MOTHER’S – Full Name AT BIRTH (First, Middle, Last, Suffix)

7b. BIRTHPLACE (City and State or Foreign Country)

8a. Bride/Applicant 2 - Full Name (First, Middle, Last, Suffix)

8b. NAME AT BIRTH (If different)

9. AGE

10a. COUNTRY

10b. STATE

10c. COUNTY

10d. CITY, TOWN OR LOCATION

10e. RESIDENCE – Street and Number

10f. ZIP CODE

11. BIRTHPLACE (City and State or Foreign Country)

12. DATE OF BIRTH (Mo., Day, Yr.)

13a. FATHER’S – Full Name (First, Middle, Last, Suffix)

13b. BIRTHPLACE (City and State or Foreign Country)

14a. MOTHER’S – Full Name AT BIRTH (First, Middle, Last, Suffix)

14b. BIRTHPLACE (City and State or Foreign Country)

CONFIDENTIAL INFORMATION: INFORMATION BELOW WILL NOT APPEAR ON CERTIFIED COPIES OF THIS RECORD

Applicant 1

Applicant 2

15a. SOCIAL SECURITY NUMBER – Groom/

15b. SOCIAL SECURITY NUMBER – Bride/

16. If previously married, last marriage ended either by –

Groom/Applicant 1:

Death

Dissolution

Annulment

Date Marriage Ended (Mo., Day, Yr.)

Bride/Applicant 2:

Death

Dissolution

Annulment

Date Marriage Ended (Mo., Day, Yr.)

17a.

17b.

Is groom/applicant 1 of Hispanic or Latino Origin

Is bride/applicant 2 of Hispanic or Latino Origin

RACE

18a. Groom/Applicant 1

18b. Bride/Applicant 2

Check one or more races to indicate what each person considers him/herself to be

White

Black or African American

American Indian or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

Fee for the marriage license is $25. A certified copy of the marriage license is required in order for the applicant to

change the last name, e.g. Driver’s License, Social Security, etc. The cost of a certified copy is $9. Total fee at the

time of application is $34. We accept cash, credit card (portal fee will be applied) or money orders made payable

to the Sarpy County Clerk. The certified copy will be mailed to applicant 1’s address once the license is filed unless

otherwise specified at the time of application. Hours for marriage licenses are 8:00 a.m. to 4:30 p.m. Monday

through Friday.

Applicant 1 PHONE #:

Applicant 2 PHONE #:

---------------------------------------------------------------------------------------------------*For office use only*---------------------------------------------------------------------------------------------------

Identification Type:

Number: