MIKE POWELL, JUDGE Warren County Common Pleas Court Probate-Juvenile Division 570 Justice Drive Lebanon, Ohio 45036 APPLICATION FOR CONSENT TO MARRY OF JUVENILE COURT Juv. R. 42 (C) and (D). Applicant does hereby make this application to the Warren County Juvenile Court for consent to marry in accordance with Juv. R. 42 (C) and (D) and R.C. section 3101.01. The applicant certifies that the information contained in the within application is true to the best of the applicant’s knowledge, information and belief and further acknowledges that the Warren County Juvenile Court will rely upon the information contained herein in determining whether to consent to the applicant’s marriage. 1. Name: ______________________________________________________ 2. Address: ______________________________________________________ ______________________________________________________ 3. Date of birth and current age: Select Month Day Year ______________________________________________________ ______________________________________________________ 4. The applicant: Is currently pregnant (Certificate of physician verifying pregnancy is attached hereto); or Has already delivered her child (A copy of the child’s birth certificate is attached hereto). 5. The applicant is is not a ward of the Juvenile Court. 6. Other facts which may assist the Warren County Juvenile Court in determining whether to consent to the applicant’s marriage. 7. Parental consent is not required because: Parent(s) resides in a foreign country. Parent(s) has/have neglected or abandoned the applicant for a period of one year or longer immediately preceding the application for a marriage license. Parent(s) has/have been adjudged incompetent. WCJC Form 17 American LegalNet, Inc. www.FormsWorkFlow.com Parent(s) is/are an inmate(s) of a state mental or correctional institution. Parent(s) has/have been permanently deprived of parental rights and responsibilities for the care of the minor and the right to have the minor live with the parent(s) and to be the legal custodian of the minor by a court exercising juvenile jurisdiction. Parent(s) has/have been deprived of parental rights and responsibilities for the care of the minor and the right to have the minor live with the parent and to be the legal custodian of the minor by the appointment of a guardian of the person of the minor by the probate court or by another court of competent jurisdiction. Select Month Year Day ___________________________________________ Date _________________________________________________________ Applicant’s Signature _________________________________________________________ Applicant’s Address _________________________________________________________ _________________________________________________________ Applicant’s Telephone Number(s) (Day and Evening) PARENTAL CONSENT TO THE GRANTING OF THE APPLICATION The undersigned being parents of the applicant whose consent to the marriage is required by law do hereby consent to the granting of this application. Select Month Day Year ___________________________________________ Date _________________________________________________________ Father’s Signature _________________________________________________________ Father’s Address _________________________________________________________ _________________________________________________________ Father’s Telephone Number(s) (Day and Evening) Select Month Day Year ___________________________________________ Date _________________________________________________________ Mother’s Signature _________________________________________________________ Mother’s Address _________________________________________________________ _________________________________________________________ Mother’s Telephone Number(s) (Day and Evening) WCJC Form 17 American LegalNet, Inc. www.FormsWorkFlow.com