Fillable Marriage Application2019may 9 External APPLICATION FOR LICENSE TO MARRY IN IOWA

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Marriage Application2019may 9 External APPLICATION FOR LICENSE TO MARRY IN IOWA

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MARRIAGE APPLICATION INSTRUCTIONS
Complete all 3 pages of the application, and send along with check or
money order (payable to the Polk County Recorder) to:
POLK COUNTY RECORDER
VITAL RECORDS DEPARTMENT
111 COURT AVE STE 245
DES MOINES, IA 50309-2251
If you have any questions, contact our Vital Records Department at 515-286-3781.
Once we have received the completed application, either of the parties to the
application may pick up the license from our office.
If the license
is n
ot picked up within 6 months from the date of application, the application is
considered null and void.
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
Iowa Department of Public Health, Bureau of Health Statistics Page 2 of 2 FORM #588-0224VR (Updated May 15, 2018)
AFFIDAVIT OF COMPETENT AND DISINTERESTED
PERSON
as to age and qualification of the contracting
parties
Type or print legibly in black or dark blue ink. Do not use all capital letters.
I, the below noted disinterested person, affirm that I am acquainted with
,
who is
,
who is
years of age.
I affirm that I am a lawfully competent and disinterested person and impartial to the result of this pending transaction. I further
affirm that both parties are unmarried and able to enter into a civil contract, that there is no legal disability to the marriage of said
parties, and that their marriage is to be solemnized in a ceremony performed by an authorized officiant within the State of Iowa.
NOTARY PUBLIC SIGNATURE TO AFFIDAVIT OF DISINTERESTED PERSON
Notary Public cannot serve as disinterested person.
I affirm that the information I provided above is true and accurate to the best of my knowledge.
Disinterested Person Signature
Date Signed
State of
County of
ss
Signed and affirmed in my presence by
Write name exactly as appears on I.D.
Notary Public’s Signature
Date Signed
Notary Address & Expiration
NOTICE TO APPLICANTS: PLEASE READ CAREFULLY!
• Applicants aged 16 or 17 years old must also present a completed Consent to Marriage form for approval to a judge of the
district court in the county from which the marriage license is to be obtained. Age 15 and under may NOT marry in Iowa.
• Pursuant to Iowa Code section 595.3A, the laws of this state affirm a party’s right to enter into this marriage and at the same time
to live within the marriage under the full protection of the laws of this state with regard to violence and abuse. Neither party to the
marriage is the property of the other. Assault, sexual abuse, and willful injury of a spouse or other family member are violations of
the laws of this state and are punishable by the state.
• Applicants’ social security numbers are collected pursuant to Iowa Code section 595.4 and 42 USC 405(c)(2), as amended by
Section 1090(b) of Public Law 105-34. The law authorizes the Internal Revenue Service (IRS) to use social security numbers for
determining Earned Income Tax Credit compliance on income tax returns and to authorize the State Registrar to report the social
security number to the Child Support Recovery Unit.
• The $35.00 fee must accompany this application.
• Return this form and fee to the County Registrar of Vital Records in the county where you want your record to be filed.
• Review the Marriage Instructions handout for more details about obtaining the certified copy of your Certificate of Marriage.
*** CONFIDENTIAL INFORMATION REQUIRED BY IOWA CODE SECTION 595.4 ***
*** ADMINISTRATIVE PURPOSES ONLY *** NOT FOR PUBLIC VIEWING, DISTRIBUTION OR PUBLICATION ***
Party A Social Security Number
Party B Social Security Number
Anticipated Ceremony Date
Anticipated Officiant
NOTARY
PUBLIC’S
SEAL
Marriage Certificate Address Update
Effective January 1, 2001, the $35.00 application fee for your License to Marry in Iowa includes a certified copy of
your marriage record after it has been properly registered. To ensure that you receive your certified copy as
intended, please complete the following information so that we may have your correct information after marriage.
The application fee is non-refundable if the marriage event does not occur as planned. Please provide a complete
mailing address and daytime phone number where you can be reached.
MAIL CERTIFIED COPY TO:
____________________________________________________________________________________
Couples’ Names after Marriage
____________________________________________________________________________________
Street Address/Apt.#/Route#/P.O. Box
____________________________________________________________________________________
City State Zip Code
Daytime Contact Phone # ____________________________________________________
The following immediate family member will arrange to pick up the License to Marry Packet (Sibling, Parent, or
Grandparent only)
Designated Person to Receive Packet _______________________________
Party A Signature ___________________________________________
And/Or
Party B Signature____________________________________________
------------------------------------------------------------------------------------------------------------------------------------------
(Office Use Only)
I affirm that the information on the Certificate of Marriage is true and accurate per the application submitted.
________ Party A Initials
________ Party B Initials
Julie M. Haggerty
Polk County Recorder
Registrar of Vital Records
111 Court Ave Ste 250
Des Moines, IA 50309-2251
515-286-3160
www.polkrecorder.com
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Marriage Application2019may 9 External APPLICATION FOR LICENSE TO MARRY IN IOWA

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Completed 28 June 2020

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