Fillable WISCONSIN MARRIAGE LICENSE APPLICATION (Brown County Information Services)

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WISCONSIN MARRIAGE LICENSE APPLICATION (Brown County Information Services)

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WARNING: Per ss. 765.08 and 765.20, Wis. Stats., persons intending to marry in the state must complete this form and obtain a valid license to marry before the marriage can take
place. Any person falsely swearing to or affirming any parts of this application has violated s. 765.30, Wis. Stats., and may be fined not more than $10,000 or imprisoned not more
than 9 months, or both. The non-confidential portion of this form is an open record and may be reviewed by any member of the public. Reports of fraudulent information will be
reported to local law enforcement. This office reserves the right to verify information provided by the applicants.
STATE OF WISCONSIN
Chapter 69, Wis. Stats.
Page 1 of 3
DEPARTMENT OF HEALTH SERVICES
Division of Public Health
F-05061 (Rev 05/15)
18. CURRENT NAME - First
Middle
Last Suffix
26. RESIDENCE – COUNTRY/STATE
WISCONSIN MARRIAGE LICENSE APPLICATION
See Instructions on the back of this form before completing this form.
19. BIRTH NAME - First Middle
Last
Suffix
2. Do you require permission from a parent or guardian to marry?
27. COUNTY 28. CITY
3. Have you been a resident of this county for 30 days?
4. What document did you bring as proof of current residence?
21. BIRTHPLACE - COUNTRY
22. STATE
29. CURRENT NAME - First
Middle
Last Suffix
37. RESIDENCE – COUNTRY/STATE 38. COUNTY 39. CITY
32. BIRTHPLACE - COUNTRY
33. STATE
34. MOTHER’S BIRTH NAME – First, Middle, Last 35. FATHER’S BIRTH NAME – First, Middle, Last
APPLICANT 1APPLICANT 2
50. DATE OF MARRIAGE 51. COUNTY OF MARRIAGE 52. CITY, VILLAGE, OR TOWNSHIP 53. CVT INDICATOR
City
Village
Township
23. MOTHER’S BIRTH NAME – First, Middle, Last 24. FATHER’S BIRTH NAME – First, Middle, Last
40. LICENSE NUMBER 41. ISSUED BY COUNTY CLERK/DEPUTY 42. DATE ISSUED 43. ISSUING COUNTY
44. APPLICATION TAKEN BY 45. FEE PAID
46. 5-DAY WAITING WAIVED?
47. WAIVER FEE PAID
County
} SS
I, (Print Name) __________________________________________,
hereby swear or affirm that the information provided on this application
is correct to the best of my knowledge and belief and that I am free to
marry under the laws of this state on the date of the intended marriage.
SIGNATURE – APPLICANT 1
Subscribed and sworn to or affirmed before me this _____ day of
_________________ in the year _________
SIGNATURE – COUNTY CLERK or DEPUTY
County, Wisconsin
County
} SS
SIGNATURE – APPLICANT 2
Subscribed and sworn to or affirmed before me this _____ day of
_________________ in the year _________
SIGNATURE – COUNTY CLERK or DEPUTY
County, Wisconsin
49. STATE OF WISCONSIN
54. OFFICIANT NAME
55. OFFICIANT MAILING ADDRESS
56. PHONE NUMBER
15. Are you related to each other? (if yes, enter relationship)
48. STATE OF WISCONSIN
I, (Print Name) __________________________________________,
hereby swear or affirm that the information provided on this application
is correct to the best of my knowledge and belief and that I am free to
marry under the laws of this state on the date of the intended marriage.
MARRIAGEID
APPLICANT 1
9. Do you require permission from a parent or guardian to marry?
10. Have you been a resident of this county for 30 days?
11. What document did you bring as proof of current residence?
12. Have you been married previously? 13. How did your last marriage end? (Must provide proof) 14. Date your last marriage ended
8. What document did you bring as proof of Identity & Age?
APPLICANT 2
16. If first cousins and female applicant is under 55 years old, check which applicant is sterile.
Applicant 1 Applicant 2
17. Which set of labels should your marriage license worksheet and marriage certificate use?
Groom/Bride Bride/Bride Groom/Groom Spouse/Spouse
No Yes, relationship ___________________
No Yes, number of this marriage:____ Death Divorce/Annulment
1. What document did you bring as proof of Identity & Age?
5. Have you been married previously? 6. How did your last marriage end? (Must provide proof) 7. Date your last marriage ended
No Yes, number of this marriage:____ Death Divorce/Annulment
20. DATE OF BIRTH
30. BIRTH NAME - First Middle
Last
Suffix
31. DATE OF BIRTH
57. OFFICIANT EMAIL
Not Applicable
25. Same Sex
Parents?
36. Same Sex
Parents?
No
Yes
No
Yes
No
Yes
No
Yes
Brown
Brown
STATE OF WISCONSIN
Chapter 69, Wis. Stats.
Page 2 of 3
DEPARTMENT OF HEALTH SERVICES
Division of Public Health
F-05061 (Rev 05/15)
INSTRUCTIONS FOR COMPLETING THE MARRIAGE LICENSE APPLICATION FORM
You must provide certain information to prove your eligibility to marry and to determine the appropriate jurisdiction for issuance of the
marriage license.
Each applicant MUST be prepared to show legal documentation to establish:
1. Your age – a certified copy of your birth certificate and driver’s license
2. Identity – a certified copy of your birth certificate and social security card
3. Your residence – mail, voter registration, driver’s license
4. How your last marriage ended (if applicable) – a certified copy of the divorce certificate or divorce/annulment decree or a
certified copy of the death certificate
Under specific circumstances, you may also need:
5. If you are under 18 or have a guardian, you may also need permission from your guardian
6. If applicants are related to each other closer than 2
nd
cousins, proof of sterility may be required
***Contact the County Clerk if you are unsure about any documentation you must provide when applying for the marriage license.***
Items 2 & 9 - GUARDIANSHIP
Specify if you are under the guardianship of another person who is required to give permission for you to marry. If you are under guardianship that requires your guardian’s
permission, ask the County Clerk for instructions about the guardian’s permission form.
Items 3-4 & 10-11 - PROOF OF RESIDENCE
Specify whether you were or were not a resident of the county of application for the last 30 days prior to the date of application. Be prepared to show proof to the County
Clerk.
Items 5-7 & 12-14 - PREVIOUS MARRIAGE
Enter the number of this marriage. If this is your first marriage, enter 1. Enter the method by which your last marriage ended – either divorce, annulment, or death. Be
prepared to show proof. Enter the date the last marriage ended. If this is your first marriage, then leave item ‘last marriage ended by’ and ‘date last marriage ended’ blank.
Item 15 & 16 - APPLICANTS RELATED
Under Wisconsin law, applicants closer than second cousins are not allowed to marry unless they are first cousins and can prove sterility.
Item 17 – LICENSE AND CERTIFICATE LABELS
There are 4 label options. Select the set of labels that you prefer to be used on your license and marriage certificate.
Items 18 & 29 - CURRENT NAMES (First, Middle, Last)
Enter your first name, full middle name, and current last name that you are currently using. If you are using a last name other than the name on your legal birth certificate or a
last name acquired from a previous marriage, ask the County Clerk for instructions on how to complete this item.
Items 19 & 30 - BIRTH NAMES (First, Middle, Last)
Enter your birth name. Complete this item even if the name is the same as the current name. This name should be what appears on your birth certificate.
Items 20 & 31 - DATES OF BIRTH
Enter the date your were born as it appears on your birth certificate. Supply proof of age as directed by the County Clerk.
Items 21-22 & 32-33 - COUNTRY & STATE OF BIRTH
Enter the country and state where you were born. If you were not born in the United States, enter only the country.
Items 23, 34 - MOTHER’S NAME
Enter the first, full middle, and last name of the applicant’s mother. This should be the mother’s name as it appears on your birth certificate. If you were adopted, the name
entered should be the name or your adoptive mother. If you have same sex parents, indicate Yes in item 27 or 38 as appropriate.
Items 24, 35 - FATHER’S NAME
Enter the first, full middle, and last name of the applicant’s father. This should be the father’s name as it appears on your birth certificate. If you were adopted, the name
entered should be the name or your adoptive father. If you have same sex parents, indicate Yes in item 27 or 38 as appropriate.
Items 26-28 & 37-39 - RESIDENCE
Enter the country, state, county, and city in which you claim residency. This may differ from the state where you receive your mail. If you are not a residence of the United
States, enter only the country.
Items 40-47 - will be entered by the County Clerk.
Items 48 & 49 MUST be completed in the presence of the County Clerk. Do not sign until in the presence of the County Clerk.
Items 50-59 – MARRIAGE AND OFFICIANT
Enter the marriage date, location, officiant, and witness information as currently planned.
WISCONSIN MARRIAGE LICENSE APPLICATION
STATE OF WISCONSIN
Chapter 69, Wis. Stats.
Page 3 of 3
DEPARTMENT OF HEALTH SERVICES
Division of Public Health
F-05061 (Rev 05/15)
SOCIAL SECURITY NUMBER
MARRIAGE LICENSE APPLICATION
HISPANIC ORIGIN
APPLICANT 1
APPLICANT 2
No, not Spanish/Hispanic/Latino(a)
Yes, Mexican, Mexican American, Chicano(a)
Yes, other Spanish/Hispanic/Latino(a) (e.g., Spaniard, Salvadoran, Dominican, Colombian) (specify):
Yes, Puerto Rican
RACE
White
Black or African American
Vietnamese
Laotian
American Indian or Alaska Native
Specify:
Asian Indian
Chinese
Filipino
Japanese
Korean
Other
Specify:
Hmong
Other Asian
Specify:
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
Specify:
CONFIDENTIAL INFORMATION [ss.69.20 (2) and 69.16, Wis. Stats.] Information collected below is confidential except as noted.
1. Social Security Numbers may only be released for Child Support Enforcement program purposes per s. 69.20(3), Wis. Stats., and federal law 42 USC 66(a)(5).
You MUST provide your Social Security Number if you have ever been assigned a number. If you have a Social Security Number but refuse to give it, the County
Clerk, cannot issue you a marriage license.
2. The street address entered below can be given to a law enforcement office who requests this information under provisions of ss.765.09 (3) and 765.20 (2),
Wis. Stats. The length of time the address is kept on file varies by county.
3. The contact information may be given to the Register of Deeds or the State Vital Records Office, if necessary, to ensure the timely filing of an accurate and
complete marriage certificate.
8
th
grade or less
High school graduate or GED completed
9
th
– 12
th
grade, no diploma
Some college credit, but no degree
Associate degree (e.g., AA, AS)
Bachelor’s degree (e.g., BA, BS)
Master’s degree (e.g., MA, MS, MBS, MSW)
Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DDS, JD)
Yes, Cuban
EDUCATION Check the box that best describes the highest degree or level of school completed)
SOCIAL SECURITY
NUMBER
HISPANIC ORIGIN
No, not Spanish/Hispanic/Latino(a)
Yes, Mexican, Mexican American, Chicano(a)
Yes, other Spanish/Hispanic/Latino(a) (e.g., Spaniard, Salvadoran, Dominican, Colombian) (specify):
Yes, Puerto Rican
RACE
White
Black or African American
Vietnamese
Laotian
American Indian or Alaska Native
Specify:
Asian Indian
Chinese
Filipino
Japanese
Korean
Other
Specify:
Hmong
Other Asian
Specify:
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
Specify:
8
th
grade or less
High school graduate or GED completed
9
th
– 12
th
grade, no diploma
Some college credit, but no degree
Associate degree (e.g., AA, AS)
Bachelor’s degree (e.g., BA, BS)
Master’s degree (e.g., MA, MS, MBS, MSW)
Yes, Cuban
EDUCATION Check the box that best describes the highest degree or level of school completed)
ISSUANCE METHO
D
Pick Up
Mail to Officiant
Mail to Applicant Address
Other:
APPLICANT EMAIL
MAIL TO ADDRESS
CITY
STATE ZIP
MARRIAGEID
APPLICANT PHONE NUMBER
Doctorate (e.g., MD, DDS, JD) or professional degree (e.g.; PhD, EdD)
MAIL TO NAME
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Completed 2 July 2021

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