Iowa Department of Public Health, Bureau of Health Statistics Page 1 of 2 FORM #588-0224VR (Updated May 15, 2018)
STATE OF IOWA
IOWA DEPARTMENT OF PUBLIC HEALTH
Bureau of Health Statistics
and Vital Records
County/IV#
POLK / _______________________
License No.
______________________________
Date
of Application
________________________
Valid Date of License ______________________
APPLICATION FOR LICENSE TO MARRY IN IOWA
Type or print legibly in black or dark blue ink. Do not use all capital letters.
PARTY A
(Information to be completed by the first applicant)
Check One (Optional)
Bride
Groom
Spouse
FULL LEGAL NAME BEFORE MARRIAGE
(Include any generational suffix after last name)
First Middle (If any) Current Last (Surname) Last Name Prior to ANY Marriage
FULL LEGAL NAME CHANGE ADOPTED THROUGH MARRIAGE
(Include any generational suffix after last name)
First Name After Marriage Middle Name (If any) After Marriage Last Name (Surname) After Marriage
CURRENT PLACE
OF RESIDENCE
State
City (Optional)
County (Optional)
STATE OF BIRTH
(If not United States, name of foreign country)
DATE OF BIRTH
(Month, Day, Year)
GENDER
(Optional)
PARTY A’S PARENT Optional
Check One
Mother Father Parent
Parent’s Name Prior to any Marriage
PARTY A’S PARENT Optional
Check One
Mother Father Parent
Parent’s Name Prior to any Marriage
PARTY B
(Information to be completed by the second applicant)
Check One (Optional)
Bride
Groom
Spouse
FULL LEGAL NAME BEFORE MARRIAGE
(Include any generational suffix after last name)
First Middle (If any) Current Last (Surname) Last Name Prior to ANY Marriage
FULL LEGAL NAME CHANGE ADOPTED THROUGH MARRIAGE
(Include any generational suffix after last name)
First Name After Marriage Middle Name (If any) After Marriage Last Name (Surname) After Marriage
CURRENT PLACE
OF RESIDENCE
State City (Optional)
County (Optional)
STATE OF BIRTH
(If not United States, name of foreign country)
DATE OF BIRTH
(Month, Day, Year)
GENDER
(Optional)
PARTY B’S PARENT Optional
Check One
Mother Father Parent
Parent’s Name Prior to any Marriage
PARTY B’S PARENT Optional
Check One
Mother Father Parent
Parent’s Name Prior to any Marriage
SIGNATURE NOTARY AFFIRMATION
(Each party must sign and date this form in the presence of an authorized Notary Public. Each party
must show valid U.S. government-issued identification when signing. The Notary Public completes and signs below.
PARTY A: I affirm that the information I provided above is true
and accurate and that I intend for my legal name after marriage to
be as stated above.
PARTY B: I affirm that the information I provided above is true and
accurate and that I intend for my legal name after marriage to be as
stated above.
PARTY A SIGNATURE Date Signed PARTY B SIGNATURE Date Signed
State of
County of ss State of County of ss
Signed and affirmed by
Signed and affirmed by
Write name exactly as appears on I.D.
Write name exactly as appears on I.D.
Notary Public’s Signature for Party A Date Signed Notary Public’s Signature for Party B Date Signed
Notary Address & Expiration
NOTARY
SEAL
Notary Address & Expiration
NOTARY
SEAL
PARTY B PARTY A
NOTARY PUBLIC
