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INFORMATION BELOW FOR USE BY VITAL STATISTICS ONLY – NOT TO BE RECORDED
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 Flo rida.
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
County of
Personally Known OR Produced identification
Type of Identification Produced
State of
County of
Personally Known OR Produced identification
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
SWORN
to and subscribed before
me
this day
of
,
Signat
ure
of
Deputy
Clerk (or
notary)
Print or
Type
Deputy
Clerk’s
Name
(or
notary)
(SEAL
)
Spouse’s
signature
SWOR
N
to and subscribed before
me
this
day
of
,
Signat
ure
of
Deputy
Clerk (or
notary)
Print or
Type
Deputy
Clerk’s
Name
(or
notary)
(SEAL)
DH 743A, 01/2015 Florida Administrative Code Rule 64V-1.020 (Obsoletes Previous Editions)
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signature
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click to sign
signature
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click to sign
signature
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signature
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