Fillable APPLICATION FOR LICENSE AND CERTIFICATE OF MARRIAGE

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APPLICATION FOR LICENSE AND CERTIFICATE OF MARRIAGE

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APPLICATION FOR LICENSE AND CERTIFICATE OF MARRIAGE
ACR206(Rev.09/2019) AvailableinAlternateFormats Page1of2
TO ENSURE THAT THE CORRECT MARRIAGE LICENSE IS ISSUED TO YOU, PLEASE PROVIDE THE INFORMATION REQUESTED BELOW:
MUST BE LEGIBLE (Blue or Black Ink ONLY)
1A. FIRST NAME 1B. MIDDLE
1C. CURRENT LAST 1D. LAST NAME AT BIRTH (IF DIFFERENT THAN 1C)
2. DATE OF BIRTH (MM/DD/CCYY) 3. STATE/COUNTRY OF BIRTH 4. #PREV. MARRIAGES/SRDP 5A. LAST MARRIAGE/SRDP ENDED BY: 5B. DATE ENDED (MM/DD/CCYY)
DEATH DISSO ANNULMENT TERM SRDP N/A
6. ADDRESS 7. CITY 8. STATE/COUNTRY 9. ZIP CODE
10A. FULL BIRTH NAME OF FATHER/PARENT 10B. STATE OF BIRTH (IF OUTSIDE U.S. ENTER COUNTRY)
11A. FULL BIRTH NAME OF MOTHER/PARENT 11B. STATE OF BIRTH (IF OUTSIDE U.S. ENTER COUNTRY)
12A. FIRST NAME 12B. MIDDLE
12C. CURRENT LAST 12D. LAST NAME AT BIRTH (IF DIFFERENT THAN 12C)
13. DATE OF BIRTH (MM/DD/CCYY) 14. STATE/COUNTRY OF BIRTH 15. # PREV. MARRIAGES/SRDP 16A. LAST MARRIAGE/SRDP ENDED BY: 16B. DATE ENDED (MM/DD/CCYY)
DEATH DISSO ANNULMENT TERM SRDP N/A
17. ADDRESS 18. CITY 19. STATE/COUNTRY 20. ZIP CODE
21A. FULL BIRTH NAME OF FATHER/PARENT 21B. STATE OF BIRTH (IF OUTSIDE U.S. ENTER COUNTRY)
22A. FULL BIRTH NAME OF MOTHER/PARENT 22B. STATE OF BIRTH (IF OUTSIDE U.S. ENTER COUNTRY)
WE, THE UNDERSIGNED DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT WE ARE UNMARRIED AND THAT THE FOREGOING
INFORMATION IS TRUE AND CORRECT TO THE BEST OF OUR KNOWLEDGE AND BELIEF. WE FURTHER DECLARE THAT NO LEGAL OBJECTION TO THE MARRIAGE NOR TO THE
ISSUANCE OF A LICENSE IS KNOWN TO US. WE ACKNOWLEDGE RECEIPT OF THE INFORMATION REQUIRED BY FAMILY CODE SECTION 358 AND HEREBY APPLY FOR A LICENSE
AND CERTIFICATE OF MARRIAGE.
23. SIGNATURE OF PERSON LISTED IN FIELDS 1A-1D 24. SIGNATURE OF PERSON LISTED IN FIELDS 12A-12D
NEW MIDDLE AND LAST NAME OF PERSON LISTED IN 1A-1D (IF ANY) FOR USE UPON SOLEMNIZATION OF THE MARRIAGE (SEE REVERSE FOR INFORMATION)
30A. FIRST – MUST BE SAME AS 1A 30B. MIDDLE 30C. LAST
NEW MIDDLE AND LAST NAME OF PERSON LISTED IN 12A-12D (IF ANY) FOR USE UPON SOLEMNIZATION OF THE MARRIAGE (SEE REVERSE FOR INFORMATION)
31A. FIRST – MUST BE SAME AS 12A 31B. MIDDLE 31C. LAST
Clerk’s Use Only
ML#_____________________________________
RCPT# __________________________________
POA (Send Original to Records Coordination Desk)
FIRST PERSON’S DRIVER’S LICENSE / IDENTIFICATION NO:
ISSUE DATE:
EXPIRATION DATE:
Clerk’s File Stamp
SECOND PERSON’S DRIVER’S LICENSE / IDENTIFICATION NO:
ISSUE DATE:
EXPIRATION DATE:
License type applied for (CHECK ONE): Public ($100.00) Confidential ($110.00)
The person performing the ceremony will be (CHECK ONE):
Judge Clergy Person (Minister, Priest, Rabbi, etc.)
Deputy Commissioner of Marriages Denomination without Clergy: Buddhist, Muslim, Bahai, Wiccan, etc.
Date of Ceremony _____________________________ City of Ceremony___________________________
Teleph
one Number for First Person
: _______________________ Telephone Number for Second Person: _______________________
NEW NAMES
(IF ANY)
Groom Bride N/A
SECOND PERSON DATA
Groom Bride N/A
FIRST PERSON DATA
AFFIDAVIT
APPLICATION FOR LICENSE AND CERTIFICATE OF MARRIAGE
ACR206(Rev.09/2019)AvailableinAlternateFormats Page2of2
PLEASE READ BEFORE COMPLETING APPLICATION
With this application, you are applying for a marriage license issued pursuant to Family Code Section 359.
When you sign this application, you are stating under penalty of perjury that the information you have provided is true and
correct, that you are currently both unmarried, and that there is no legal objection to the marriage.
Marriage licenses are valid for 90 days from the date of issuance. You must be married on or after the issuance
date, and on or before the expiration date of the license. Licenses not used within this timeframe are void.
No refunds are given for marriage licenses purchased in error, lost or destroyed.
The cost of a public marriage license is:
$100.00 payable to Riverside County Clerk by cash, check or debit ($2.50 fee)
The cost of a confidential marriage license is:
$110.00 payable to Riverside County Clerk by cash, check or debit ($2.50 fee)
Please check the ty
pe of marriage license you would like to apply for:
License and Certificate of Marriage (VS 117) — This is the standard type of marriage license. This type of
marriage license requires the signature of at least one witness and one person solemnizing the marriage.
With a Public Marriage License, you may be married anywhere in California in the presence of at least one witness, and
your marriage must be solemnized by a person authorized to perform marriages in California as provided for in Family
Code Sections 400-401.
License and Certificate of Marriage for Denominations Not Having Clergy (VS 115) — This type of license
is used for the recording of marriages for members of religious societies or denominations that do not have clergy for the
purpose of solemnizing a marriage.
License and Certificate of Declaration of Marriage (VS 116) — This type of license is used for the recording of a
marriage that was licensed and occurred over one year ago; however, no official record exists.
Confidential License and Certificate of Marriage (VS 123) — Confidential marriage licenses may only be issued
to unmarried parties who are at least 18 years old and have been living together as spouses. Since the confidential
marriage license requires the signature of a marriage officiant, they are not available to members of religious
denominations not having clergy. Certified copies of the marriage license and certificate may only be issued to the couple.
With a Confidential Marriage License, you must be married within the state of California. The couple MUST reside at the
same address. No witnesses are necessary for the marriage ceremony. The signatures of the parties in fields 23 and 24
affirm that they meet the requirements to receive a confidential marriage license.
PLEASE CAREFULLY READ THE FOLLOWING INFORMATION REGARDING NAME CHANGES:
The Name Equality Act of 2007 (AB 102, Chapter 567, Statutes of 2007) gives specific rights to parties at the time they are applying for a California marriage
license to choose and list on the marriage license the new name that each party will go by after marriage. Parties are not required to have the same name,
nor are they required to change their name. If one or both parties do not wish to identify a new name on the marriage license, the fields on the
marriage license will be completed using two single dashes. If one or both of the parties want to have their new name(s) reflected on the marriage license,
the new name must be entered on the marriage license application at the time they are applying for the marriage license. The parties may choose any of
the following middle or last names as the names they wish to be known as after marriage (FC § 306.5(b) (2)]:
A person may adopt any of the following middle names: A person may adopt any of the following last names:
The current last name of either spouse
The last name of
either spouse given at birth
A h
yphenated combination of the current middle name and the cu
rrent last
name of the pe
rson or spouse
A h
yphenated combination of the current middle name and the last
name
given at birth of t
he person or spouse
The current last name of either spouse
The last name of
either spouse given at birth
A name combining into a single last name all or a
segment of the cu
rrent
last name or the l
ast name of eithe
r spouse given at birth
A hyphenated combination of last names
A non-hyphenated combination of last names
NOTE
: You may not change your first name using
this process.
IMPORTANT: You may not amend the marriage license after it has been issued or add or change the name
you wish to be known as after you are married. The name you indicate on the marriage license application
will be your name on the marriage license/certificate and cannot be changed by the County Clerk. Any
changes or corrections to the name after the marriage license has been issued will require a COURT
ORDERED NAME CHANGE. If you have any questions, please consult with an attorney prior to applying.
We
, the undersigned declare that the information on our marriage license is true and correct, and understand that any mistakes or
corrections to the New Name fields (30A-31C) on the marriage license will require a COURT ORDERED NAME CHANGE.
Signat
ure First Person:
_____________________________ Signature Second Person: ________________________________
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APPLICATION FOR LICENSE AND CERTIFICATE OF MARRIAGE

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Completed 12 November 2021

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