State of Rhode Island Marriage Worksheet
Party A Bride Groom Spouse
Date of application _____________________
Current name __________________________________________________
Last name on birth certificate (if different) _____________________________
Current Mailing Address
Street/PO box ___________________________________________________
City/Town ______________________________________________________
State ___________________________ ZIP ___________________________
City/Town, state of residence (if different) _____________________________
State of birth (if not US, name country) _______________________________
Date of birth _____________________
Male Female Age _______
Are you currently under legal guardianship? Yes
No
Social Security Number* ________-______-____________
Mother/parent’s full birth name _____________________________________
State of mother/parent’s birth _____________________________________
(if not US, name country)
Father/parent’s full birth name _______________________________________
State of father/parent’s birth ________________________________________
(if not US, name country)
Party A
Number of previous marriages/civil unions/domestic partnerships ________
Last marriage/union/partnership ended by __________________________
(Specify death, divorce, dissolution, or annulment.)
Date last marriage/union/partnership ended) _________________
SIGN IN PRESENCE OF CITY/TOWN CLERK
___________________________________________________________
Signature of Party A Date of Signature
Phone number, Party A (______) __________-_______________
Name of person completing information, if not Party A:
__________________________________________________________
Party B Bride Groom Spouse
Date of application _____________________
Current name ____________________________________________________
Last name on birth certificate (if different) _______________________________
Current Mailing Address
Street/PO box ___________________________________________________
City/Town ______________________________________________________
State ___________________________ ZIP ___________________________
City/Town, state of residence (if different) _______________________________
State of birth (if not US, name country) _________________________________
Date of Birth _____________________
Male Female Age _______
Are you currently under legal guardianship? Yes No
Social Security Number* ________-________-_________
Mother/parent’s full birth name _______________________________________
State of mother/parent’s birth _________________________________________
(if not US, name country)
Father/parent’s full birth name _______________________________________
State of father/parent’s birth _________________________________________
(if not US, name country)
Party B
Number of previous marriages/civil unions/domestic partnerships ________
Last marriage/union/partnership ended by ____________________________
(Specify death, divorce, dissolution, or annulment.)
Date last marriage/union/partnership ended _________________
SIGN IN PRESENCE OF CITY/TOWN CLERK
___________________________________________________________
Signature of Party B Date of Signature
Phone number, Party B (______) __________-_______________
Name of person completing information, if not Party B:
__________________________________________________________
The information requested below is required by law.
It is not issued on certified copies of marriage records unless requested by Party A or Party B.
Being aware that a penalty of $1,000 or a year imprisonment, or both, is provided for in
Rhode Island law for furnishing false information to go on a vital record,
I hereby certify that the information provided above is correct.
Signatures below must be done in the presence of a city/town clerk.
*Required by Section 23-3-9(d) of the General Laws of Rhode Island, 1956, as amended. Continued on next page
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VS 4A Revised 1/2018
