LAKE County Recorder's Office
Vital Records Division
APPLICATION FOR CERTIFIED COPY OF MARRIAGE CERTIFICATE
A new Law effective January 1, 2010 changed the way certified copies of marriage certificates are issued. Certified
copies to establish the identity of a registrant can be issued only to authorized individuals, as indicated below. All
others may receive Certified Informational Copies that are not valid to establish identity.
Fees: $15 per copy (payable to the LAKE County Recorder).
I would like a Certified Copy.
This copy will establish the identity
of the registrant
(To receive a Certified Copy you must indicate
your
relationship to the registrant by selecting from the list below AND
complete the attached Sworn Statement declaring that you are eligible to
receive
the Certified Copy. Your signature on the
Sworn Statement
must be acknowledged by a Notary Public if the application is
I would like a Certified Informational Copy
will be
printed with a legend on the face of the document that
states, "INFORMATIONAL, NOT
A VALID DOCUMENT TO
ESTABLISH IDENTITY."
(A sworn statement does not need to be provided.)
NOTE: Both documents are certified copies of the original document on file with our office. With the exception of
the legend, the documents contain the exact same information
To receive a Certified Copy I am:
The registrant (one of the parties listed on the marriage certificate)
Current Driver's License or#______________
Picture ID and Date of Exp. .________________________
Parent or legal guardian of the registrant.
A member of a law enforcement agency or a representative of another governmental agency, as provided by law, who is conducting
official business. (Companies representing a government agency must provide authorization from the government agency.)
A child, grandparent, grandchild, sibling, spouse, or domestic partner of the registrant.
An attorney representing the registrant or the registrant’s estate, or any person or agency empowered by status or appointed by a court to act on
behalf of the registrant or the registrant’s estate. (If you are requesting a Certified Copy under a power of attorney, please include a copy of the power
of attorney with this application form.)
DO NOT COMPLETE THE REST OF THIS FORM BEFORE READING THE DETAILED INSTRUCTIONS ON PAGE 3.
APPLICANT INFORMATION
(PLEASE PRINT OR TYPE)
Printed Name and Signature of Person Completing Application Today's Date Telephone Number
( )
Address - Number, Street
City State
ZIP Code
Name of Person Receiving Copies, if Different From Above
No. of Copies Amount Enclosed
Purpose of Request
Mailing Address for Copies, If Different From Above
City
State ZIP Code
MARRIAGE CERTIFICATE INFORMATION (PLEASE PRINT OR TYPE)
First Name Middle Name Last Name
First Name Middle Name Last Name
Date of Marriage- Month, Day, Year
County Where License was Issued County of Marriage
FOR OFFICIAL USE ONLY
Date copy issued
Clerk Initials
Receipt # Certificate # Type Issued:
Certified Informational
Order Method:
In Person Mail
vs. 113 (01/10/10)
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