REQUEST FOR COPY OF CIVIL UNION CERTIFICATE
VS-39CU Revised: 9-10-2009
PLEASE PRINT DO NOT MAIL CASH
PARTY 1
FULL NAME
FIRST MIDDLE LAST
PARTY 2
FULL NAME
FIRST MIDDLE LAST
DATE OF CIVIL UNION (MONTH/DAY/YEAR)
PLACE OF CIVIL UNION
TOWN
PLEASE NOTE: IN ACCORDANCE WITH C.G.S. §7-51A, ONLY THE PARTIES TO THE CIVIL UNION, OFFICIATOR OF THE UNION,
TOWN CLERK OR REGISTRAR LISTED ON THE CIVIL UNION CERTIFICATE, OR OTHER PERSONS AUTHORIZED BY THE
DEPARTMENT OF PUBLIC HEALTH, SHALL BE ISSUED A CERTIFIED COPY OF A CIVIL UNION CERTIFICATE THAT CONTAINS
THE SOCIAL SECURITY NUMBERS OF THE PARTIES. ALL OTHER REQUESTERS WILL RECEIVE A CERTIFIED COPY OF THE
CIVIL UNION CERTIFICATE WITHOUT THE SOCIAL SECURITY NUMBERS.
PERSON MAKING THIS REQUEST:
NAME: ______________________________________________________________________________________________________________
FIRST MIDDLE LAST NAME
ADDRESS: ___________________________________________________________________________________________________________
NUMBER STREET
TOWN/CITY: _____________________________________ STATE: ________________ ZIP CODE: _____________________
TELEPHONE NO.:
_________________________________ E-MAIL ADDRESS (optional): ______________________________
RELATIONSHIP TO PERSON NAMED IN CERTIFICATE___________________________________
SIGNATURE:
X_____________________________________________________________________________________________
THE LEGAL FEE IS $20.00 PER COPY.
NUMBER OF COPIES WANTED: _________________ AMOUNT ATTACHED: $_________________________
FEE: $20.00 PER COPY MONEY ORDER MADE PAYABLE TO THE TOWN/CITY OF CIVIL UNION
MAIL THIS REQUEST WITH PAYMENT TO THE TOWN CLERK AT THE TOWN/CITY OF CIVIL UNION
FOR TOWN CLERK ADDRESSES PLEASE SEE ALPHABETICAL LISTING BY TOWN
at the Department of Public Health website: http://www.dph.state.ct.us/oppe/townclerks.htm
