APPLICATION FOR MARRIAGE LICENSE,
______________________________ COUNTY, TEXAS
The form and content of this application is prescribed by section 2.004 of the Texas Family Code.
WARNING: IT IS A FELONY TO FALSIFY INFORMATION ON THIS DOCUMENT. THE PENALTY FOR KNOWINGLY MAKING A FALSE STATEMENT ON THIS
FORM OR FOR SIGNING A FORM WHICH CONTAINS A FALSE STATEMENT IS 2 TO 10 YEARS IMPRISONMENT AND A FINE OF UP TO $10,000. (HEALTH AND
SAFETY CODE, CHAPTER 195, SEC. 195.003)
Woman’s Maiden Name (If Applicable)
Place of Birth (including city, county and state)
I have not been divorced within the last 30 days. □ TRUE □ FALSE
I am not presently married. □ TRUE □ FALSE
I am not presently delinquent in the payment of court ordered child support.
□ TRUE □ FALSE
The other applicant is not presently married □ TRUE □ FALSE
I am not related to the other applicant as: □ TRUE □ FALSE
an ancestor or descendant, by blood or adoption;
a brother or sister, of the whole or half blood or by adoption;
a parent's brother or sister, of the whole or half blood or by
adoption;
a son or daughter of a brother or sister, of the whole or half blood or
by adoption;
a current or former stepchild or stepparent; or
a son or daughter of a parent's brother or sister, of the whole or half
blood or by adoption;
□ I wish to make a voluntary contribution of $5.00 to promote healthy early childhood by supporting the Texas Home Visitation Program administered by the Office of Early
Childhood Coordination of Health and Human Services [Texas Family Code 2.004(13)].
I solemnly swear (or affirm) that the information I have given in this application is correct _____________________________________________
Applicant’s Signature and Date Signed
Woman’s Maiden Name (If Applicable)
Place of Birth (including city, county and state)
I have not been divorced within the last 30 days. □ TRUE □ FALSE
I am not presently married. □ TRUE □ FALSE
I am not presently delinquent in the payment of court ordered child support.
□ TRUE □ FALSE
The other applicant is not presently married □ TRUE □ FALSE
I am not related to the other applicant as: □ TRUE □ FALSE
an ancestor or descendant, by blood or adoption;
a brother or sister, of the whole or half blood or by adoption;
a parent's brother or sister, of the whole or half blood or by
adoption;
a son or daughter of a brother or sister, of the whole or half blood or
by adoption;
a current or former stepchild or stepparent; or
a son or daughter of a parent's brother or sister, of the whole or half
blood or by adoption;
□ I wish to make a voluntary contribution of $5.00 to promote healthy early childhood by supporting the Texas Home Visitation Program administered by the Office of Early
Childhood Coordination of Health and Human Services [Texas Family Code 2.004(13)].
I solemnly swear (or affirm) that the information I have given in this application is correct _____________________________________________
Applicant’s Signature and Date Signed
Mail Executed License To (Street/P.O. Box, City, State, Zip)________________________________________________________________________
For County Clerk Office Use Only
Subscribed and sworn to before me, or I certified that the applicant did not appear personally but the prerequisites for the license have been fulfilled by
§2.007 of the Texas Family Code on ________________________, 20_____ at _______________am/pm
_____________________________ County Clerk ___________________County, Texas. Ceremony Performed By_____________________________
By ___________________________________ Deputy Date of Marriage_______________ County/Place of Marriage________________________
Applicant One Identification Type (ID & Age)___________________________________ License Number _______________________
Applicant Two Identification Type (ID & Age)___________________________________ Volume _______________ Page ______________