OMB
Control # 1076-0094
Expires:
xx/xx/20xx
MARRIAGE
LICENSE APPLICATION
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
(Continued on next page)
Page
2 of 2
OMB Control # 1076-0094
Expires:
xx/xx/20xx
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
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 4660, Washington, DC 20240, or
[email protected].
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