2. AGE
3a. COUNTRY
3d. CITY, TOWN OR LOCATION 3f. ZIP CODE
7a. MOTHER'S FULL MAIDEN NAME (Fi rs t, Middl e , Maiden)
9. AGE
10a. COUNTRY
10d. CITY, TOWN OR LOCATION 10f. ZIP CODE
18a. APPLICANT #1 18b. APPLICANT #2
______ ______
______ ______
______ ______
______ ______
______ ______
APPLICANT #2: ______ Dea th ______ Diss olution ______ Annulment
17a. Is APPLICANT #1 of His pani c or Latino Origi n ____ Ye s ____ No
4. BIRTHPLACE (CITY AND STATE OR FOREI GN COUNTRY
6a. FATHER'S FULL NAME (Fi rst, Mi ddle, La s t, Suffi x)
APPLICANT #1 PHONE #
13a. FATHER'S FULL NAME (First, Middle, Las t, Suffix
14a. MOTHER'S FULL MAIDEN NAME (Fi rst, Mi ddle, La s t, Suffi x)
MAIL TO: Applicant #1 Address _______ Applicant #2 Address _______
1a. APPLICANT #1-FULL NAME (Fi rs t, Middl e , Las t, Suffix)
15a. APPLICANT #1 - SOCIAL SECURITY NUMBER
8a. APPLICANT #2-FULL NAME (Fi rs t, Middl e , Las t, Suffix)
10b. STATE
6b. BIRTHPLACE (City and State or Forei gn Country)
7b. BIRTHPLACE (City and State or Forei gn Country)
13b. BIRTHPLACE (City and Sta te or Forei gn Country)
14b. BIRTHPLACE (City and Sta te or Forei gn Country)
3e. ADDRESS
10e. ADDRESS
5. DATE OF BIRTH (Mo,Day,Yr)
16. If previous ly ma rried, l as t marriage ended ei the r by-
White
Black or African American
America n Indian or Al a ska Na tive
Asi a n
Na ti ve Ha wa i i a n or Other Pacific Is l a nder
RACE
Da te Marriage Ended (mm/dd/yyyy) _______________________________
Da te Marriage Ended (mm/dd/yyyy) _______________________________
APPLICANT #1: ______ Dea th ______ Diss olution ______ Annulment
Other Address: __________________________________________________
10c. COUNTY
Check one or more races to i ndicate wha t each pe rson considers him/hers el f to be:
The fee for the marriage license is $25. A certified copy of the marriage license is required in order for
the applicant to change their last name, e.g. Driver's License, Social Security, etc.
The cost of a certified copy is $9. (Make check payable to: Thayer County Clerk)
Where would you like the certified copy of the marriage license mailed to?
THE NAMES ON YOUR MARRIAGE LICENSE SHOULD MATCH WHAT IS ON YOUR BIRTH CERTIFICATE.
CONFIDENTIAL INFORMATION: INFORMATION BELOW WILL NOT APPEAR ON CERTIFIED COPIES OF THIS RECORD.
15b. APPLICANT #2 - SOCIAL SECURITY NUMBER
17b. Is APPLICANT #2 of His pani c or Latino Origi n ____ Ye s ____ No
APPLICANT #2 PHONE #
PLEASE INCLUDE FULL "LEGAL" NAMES FOR BOTH APPLICANTS AND PARENTS.
8b. MAIDEN LAST NAME (i f a pplicabl e)
1b. MAIDEN LAST NAME (i f a pplicabl e)
11. BIRTHPLACE (City and Sta te or Forei gn Country)
12. DATE OF BIRTH (Mo,Da y,Yr)
