Rev 2017-07-20
STATE OF MINNESOTA
COUNTY OF HENNEPIN
CERTIFICATE OF FILING
for Marriage Officiant
Pursuant to Minnesota Statutes Sections 517.04 and 517.05 and for the purpose of conducting marriages:
M
y credentials are signed by an official with the authority to do so: Yes No
My credentials state they are ministerial credentials or that I am authorized to perform marriages: Yes No
I have presented these credentials for filing: Yes No
I
am 21 years of age or older: Yes No
My authority to perform marriages: expires on has no expiration date
First name Middle name Last name
Address City State Zip
Email address Phone
MN Business Identification number: Or, I do not have a MN Business ID number
Social Security number: Or, I do not have a Social Security number
My signature below attests that all statements made and information provided are true and correct.
Tennessen warning
This application requests your Social Security number and Minnesota business identification number. State law requires you to provide
this information on a license application you make to the County in order to conduct a profession, occupation, trade, or business. If you
do not have a Social Security number or Minnesota business identification number, you may certify the same and your application will
still be processed. The data collected on this application may be shared with the State of Minnesota for the purpose of collecting taxes,
penalty, and interest owed to the State, and for the purpose of requiring returns to be filed.
Signature Date
The credentials presented have been filed in the Office of the Hennepin County Director of Licensing this _______ day
of ______________, 20___.
Designee: Location:
NOTARIZED SIGNATURE REQUIRED FOR MAIL IN ONLY
State of County of
Subscribed and sworn to before me this ____ day of ____________ 20____.
_____________________________________________
Mark if paid
Fee: $30.00
