SUPERIOR COURT OF THE DISTRICT OF COLUMBIA MARRIAGE BUREAU INFORMATION FOR MARRIAGE LICENSE APPLICATION FOR OFFICIAL USE ONLY License No: ______________ Date: ______________ Book No.: __________ Page No.: ____________ Fee Paid: ______ Date on Premarital Blood Test Cards: __________/__________ Civil Wed.: ______ Y/N (Blood test results are good for 30 days from date taken.) Consent Date: ______________/_____________ Waiver Date: _________________/______________ ▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬ I, (Applicant) ________________________________________________________________________ Prefix First MI Last do solemnly swear (affirm) that the answers to the following questions true, correct and complete. Officiant Name: _____________________________________________________________________ Prefix First MI Last Groom’s Name: ____________________________________________ DOB: _____________ Age: _________ First MI Last Groom’s S.S. No: ____________________ Telephone Nos. (H) _____________(W)______________ Former Marriages #_____ Status: __________ if Divorced, Where was Decree Obtained? ____________________ City/State Do you have any pending criminal matters? Yes _________ No ________ Legal Residence __________________________________________________________________________________ Street Address City State Zip Code Bride’s Name: ________________________________________ DOB: ________________ Age: _________ First MI Last Bride’s S.S. No: ____________________ Telephone Nos. (H) _____________(W) _______________ Former Marriages #_____ Status: __________ if Divorced, Where was Decree Obtained? _____________________ City/State Do you have any pending criminal matters? Yes _________ No ________ Legal Residence ______________________________________________________________________________________________________ Street Address City State Zip Code Kinship Between Bride and Groom: _______________________________________________ (Blood Relationship) I understand that any intentional misrepresentation and/or omission of the above information is subject to criminal sanction for perjury pursuant to D.C. Code Section 46-410. APPLICANT SIGNATURE (S): _______________________________________________ _______________________________________________ Subscribed and sworn to before me this TO REPORT WASTE, FRAUD, OR ABUSE BY ANY D.C. GOVERNMENT OFFICE OR OFFICIAL, CALL THE D.C. INSPECTOR GENERAL AT 1-800-521-1639. day of Clerk of the Court, by Deputy Clerk _________________________________________________ American LegalNet, Inc. www.USCourtForms.com