OMB Control # 1076-0094
                                       MARRIAGE LICENSE APPLICATION                   Expires: 08/31/2008 

Pursuant to 25 CFR 11.600(c) “Marriages,” please complete the following:  (Please Print)

NAME:______________________________
ADDRESS:_________________________________________________________

DATE OF BIRTH _________________ SS# ______  ____  _______ SEX: ___ M ___ F
PLACE OF BIRTH _____________________________________________

OCCUPATION:___________________________________________________________

IF YOU WERE PREVIOUSLY MARRIED, PLEASE PROVIDE THE DATE, PLACE, AND COURT IN WHICH THE MARRIAGE WAS DISSOLVED OR DECLARED INVALID _________________________________________________, OR THE DATE AND PLACE OF DEATH OF THE FORMER SPOUSE __________________________________, INCLUDING NAME OF FORMER SPOUSE ______________________________________________.

ARE YOUR RELATED TO YOUR FIANCE(E)? ____ IF SO, HOW ___________________
BLOOD TEST PERFORMED? ___ Y ___ N            BLOOD TEST ATTACHED? ___ Y ___N
LIST THE NAME AND DATE OF BIRTH OF ANY CHILD OF WHICH BOTH PARTIES ARE PARENTS, BORN BEFORE THE MAKING OF THIS APPLICATION UNLESS YOUR RELATIONSHIP WITH THIS CHILD HAS BEEN TERMINATED BY A COURT:
__________________________   _______________________   ______________________

__________________________   _______________________   ______________________

ARE CERTIFICATES OF THE RESULTS OF ANY MEDICAL EXAMINATION ATTACHED? (If required by either application of tribal ordinance, or the laws of the State) ___ Y ___N

If you are under the age of 18, please complete the following:

PARENT OR GUARDIAN’S NAME:_______________________________________
PARENT OR GUARDIAN’S ADDRESS:____________________________________
CONSENT AFFIDAVIT ATTACHED? ___ Y ___N

_______________________________
									Signature of Applicant     

Subscribed and sworn to before me this ____ day of ____________________, 20__.

                   (SEAL)

_____________________________
										Court Clerk	

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                                             PRIVACY ACT STATEMENT                           Expires  08/31/2008

Additional disclosure of the information may be made to: a Bureau of Indian Affairs or Department of the Interior employee in the course of a program review or audit; or to a Federal law enforcement agency when the agency becomes aware of a violation or possible violation of civil or criminal law.  Furnishing the information on this form is required to establish eligibility for a license for marriage or for a decree for dissolution of marriage.

PAPERWORK REDUCTION ACT STATEMENT

This information is being collected to assist eligible Indian individuals to obtain a marriage license.  You are not required to respond to this collection of information unless it displays a current and valid OMB control number.  This information will be used to determine the jurisdictional authority of the Court of Indian Offenses and the eligibility of the applicant for a marriage license.  Voluntary and complete responses to the requests for information are required in order to obtain the license or decree requested.

ESTIMATED BURDEN STATEMENT

Public reporting burden for each form is estimated to average 15 minutes per response, including the time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form.  Direct comments regarding the burden estimate or any other aspect of this form to: Bureau of Indian Affairs Information Collection Clearance Officer, 625 Herndon Parkway, Herndon, VA 20170.