PLEASE NOTE: THIS INFORMATION WILL BE TRANSFERRED ONTO YOUR PERMANENT MARRIAGE RECORD.

PORFAVOR NOTE: ESTA INFORMACION SERA TRANSFERIDA A SU ACTA PERMANENTE DE MATRIMONIO.

Applicant
Applicante

__________________________________

Applicant
Applicante

__________________________________

SSN: ____________________________________________
Numero de Seguro Social

SSN: _____________________________________________
Numero de Seguro Social

Date of Birth ________________________________ _____

Fecha de Nacimiento

Date of Birth _______________________________________

Fecha de Nacimiento

Place of Birth _____________________________________

Lugar de Nacimiento Lugar

Place of Birth ______________________________________

de Nacimiento

Present Address ___________________________________

Domicilo Actual
Street
Apt#

Present Address ____________________________________

Domicilio Actual
Street
Apt#

___________________________________________ _____
__________________________________________________
City/State/Zip Code
City/State/Zip
Code
Cuidad/Estado/CodigoPostal
Ciudad/Estado/Codigo
Postal
Phone # ( )_____________________________________
# de Telefono
#

Phone # ( )_______________________________________
de Telefono

FOR OFFICE USE ONLY

RECORDED___________________________ at ________M, in Marriage Record Book No._______ Page No. ________
____________________________Deputy