OMB Control # 1076-0094
                                       MARRIAGE LICENSE APPLICATION                   Expires: xx/xx/20xx 

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 following:
•	If the marriage was dissolved or declared invalid, provide the date, place and court in which the marriage was dissolved or declared invalid: _________________________
____________________________________________________________________
•	If your former spouse is deceased, provide the name of your former spouse, and the date and place of death:________________________________________________
____________________________________________________________________

Are you related to your fiancé(e)? ___ Y ___ N  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 the child has been terminated by a court:  
Name:______________________________________     Date of Birth: ______________
Name:______________________________________     Date of Birth: ______________
Name:______________________________________     Date of Birth: ______________
(Continue on separate sheet if necessary)

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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                                                                                                                      Expires: xx/xx/20xx

PRIVACY ACT NOTICE
This information is subject to the Privacy Act. 

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.  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: Information Collection Clearance Officer – Indian Affairs, 1849 C Street, NW, MS 4141, Washington, DC 20240.