INFORMATION BELOW FOR USE BY VITAL STATISTICS ONLY – NOT TO BE RECORDED
DH 743A, 01/2015 Florida Administrative Code Rule 64V-1.020 (Obsoletes Previous Editions)
STATE OF FLORIDA
Department of Health - Office of Vital Statistics
AFFIRMATION OF COMMON CHILD(REN) BORN IN FLORIDA
(TYPE OR PRINT INFORMATION)
Marriage Application Number:
SPOUSE’S NAME (First, Middle, Last):
SPOUSE’S MAIDEN SURNAME (If different):
Date of Birth (mm/dd/yyyy): Birthplace (State/Country)
SPOUSE’S NAME (First, Middle, Last):
SPOUSE’S MAIDEN SURNAME (If different):
Date of Birth (mm/dd/yyyy): Birthplace (State/Country)
In accordance with §741.01, Florida Statutes,
we hereby attest that we are the parents of the following minor child(ren) born in the State of Florida.
1. Name of child (As appears on Birth Certificate):
Date of birth (mm/dd/yyyy): Birth Certificate number (if known):
Place of birth (City): (County): (State): Florida
2. Name of child (As appears on Birth Certificate):
Date of birth (mm/dd/yyyy): Birth Certificate number (if known):
Place of birth (City): (County): (State): Florida
3. Name of child (As appears on Birth Certificate):
Date of birth (mm/dd/yyyy): Birth Certificate number (if known):
Place of birth (City): (County): (State): Florida
State of State of
County of County of
Personally Known OR Produced identification Personally Known OR Produced identification .
Type of Identification Produced Type of Identification Produced .
BY OUR SIGNATURES, we do hereby swear and affirm that all of the information contained herein is true and correct and may be relied upon for the issuance of a marriage license.
Spouse’s signature Spouse’s signature
SWORN to and subscribed before me this day of , SWORN to and subscribed before me this day of , .
Signature of Deputy Clerk (or notary) Signature of Deputy Clerk (or notary)
Print or Type Deputy Clerk’s Name (or notary) Print or Type Deputy Clerk’s Name (or notary)
(SEAL) (SEAL)
