COUNTY OF SAN DIEGO

ERNEST J. DRONENBURG, JR.

ASSESSOR/RECORDER/COUNTY CLERK
APPLICATION FOR LICENSE AND CERTIFICATE OF MARRIAGE
MUST BE LEGIBLE
1A. FIRST NAME 1B. MIDDLE

1C. CURRENT LAST 1D. LAST NAME AT BIRTH (IF DIFFERENT THAN 1C)
FIRST PERSON DATA
BRIDE

2. DATE OF BIRTH (MM/DD/CCYY) 3. STATE/COUNTRY OF BIRTH 4. # PREV. MARRIAGES / SRDP 5A. LAST MARRIAGE / SRDP ENDED BY: 5B. DATE ENDED (MM/DD/CCYY)
DEATH DISSO ANNULMENT TERM SRDP N/A
 GROOM

6. ADDRESS 7. CITY 8. STATE / COUNTRY 9. ZIP CODE

10A. FULL BIRTH NAME OF FATHER / PARENT 10B. STATE OF BIRTH (IF OUTSIDE U.S., ENTER COUNTRY)

11A. FULL BIRTH NAME OF MOTHER / PARENT 11B. STATE OF BIRTH (IF OUTSIDE U.S., ENTER COUNTRY)

12A. FIRST NAME 12B. MIDDLE

12C. CURRENT LAST 12D. LAST NAME AT BIRTH (IF DIFFERENT THAN 12C)
SECOND PERSON DATA
BRIDE

13. DATE OF BIRTH (MM/DD/CCYY) 14. STATE/COUNTRY OF BIRTH 15. # PREV. MARRIAGES / SRDP 16A. LAST MARRIAGE / SRDP ENDED BY: 16B. DATE ENDED (MM/DD/CCYY)
DEATH DISSO ANNULMENT TERM SRDP N/A
 GROOM

17. ADDRESS 18. CITY 19. STATE / COUNTRY 20. ZIP CODE

21A. FULL BIRTH NAME OF FATHER / PARENT 21B. STATE OF BIRTH (IF OUTSIDE U.S., ENTER COUNTRY)

22A. FULL BIRTH NAME OF MOTHER / PARENT 22B. STATE OF BIRTH (IF OUTSIDE U.S., ENTER COUNTRY)

WE, THE UNDERSIGNED DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT WE ARE UNMARRIED AND THAT THE FOREGOING INFORMATION IS TRUE AND
CORRECT TO THE BEST OF OUR KNOWLEDGE AND BELIEF. WE FURTHER DECLARE THAT NO LEGAL OBJECTION TO THE MARRIAGE NOR TO THE ISSUANCE OF A LICENSE IS KNOWN TO US. WE
AFFIDAVIT

ACKNOWLEDGE RECEIPT OF THE INFORMATION REQUIRED BY FAMILY CODE SECTION 358 AND HEREBY APPLY FOR A LICENSE AND CERTIFICATE OF MARRIAGE.

23. SIGNATURE OF PERSON LISTED IN FIELDS 1A-1D 24. SIGNATURE OF PERSON LISTED IN FIELDS 12A-12D

PHONE NUMBER FOR FIRST PERSON PHONE NUMBER FOR SECOND PERSON
SEE INFORMATION ON

NEW MIDDLE AND LAST NAME OF PERSON LISTED IN 1A-1D (IF ANY) FOR USE UPON SOLEMNIZATION OF THE MARRIAGE
REVERSE SIDE

FIRST NAME – MUST BE SAME AS 1A MIDDLE NAME LAST NAME

NEW NAMES
(IF ANY)

NEW MIDDLE AND LAST NAME OF PERSON LISTED IN 12A-12D (IF ANY) FOR USE UPON SOLEMNIZATION OF THE MARRIAGE
FIRST NAME – MUST BE SAME AS 12A MIDDLE NAME LAST NAME

Please check the type of marriage license you would like to apply Affix Label Here
for. (See reverse side of applicaiton for more information):
License and Certificate of Marriage (VS 117)
Confidential License and Certificate of Marriage (VS 123)
Denominations Not Having Clergy (VS 115)
Declaration of Marriage (VS 116)

For County Purposes Only

Information required for ceremonies performed by the San Diego County Clerk only.
Witness 1 Witness 2

Name: Name:

Address: Address:
 APPLICATION FOR LICENSE AND CERTIFICATE OF MARRIAGE

PLEASE READ BEFORE COMPLETING APPLICATION ON THE REVERSE

License and Certificate of Marriage (VS 117) — This is the standard type of marriage license. This type of marriage license requires the signature of
at least one witness and one person solemnizing the marriage.
Confidential License and Certificate of Marriage (VS 123) — Confidential marriage licenses may only be issued to unmarried parties who are at
least 18 years old and have been living together as spouses. The signatures of the parties in fields 23 and 24 affirm that they meet the
requirements to receive a confidential marriage license.
License and Certificate of Marriage for Denominations Not Having Clergy (VS 115) — This type of license is used for the recording of marriages for
members of religious societies or denominations that do not have clergy for the purpose of solemnizing a marriage.
License and Certificate of Declaration of Marriage (VS 116) — This type of license is used for the recording of a marriage that was licensed and
occurred over one year ago; however, no official record exists.

When you sign the marriage application form, you are stating under penalty of perjury that the information you have provided is true and correct,
that you are currently an unmarried couple, and that there is no legal objection to the marriage.

You may be married anywhere in California by a person authorized to perform marriages in California pursuant to Family Code Section 400.
Check the license to see what the requirements are for witnesses and solemnization.

Marriage licenses are valid for 90 days from the date of issuance. You must be married on or after the issuance date, and on or before the
expiration date of the license. Licenses not used within this timeframe are void.

No refunds are given for marriage licenses purchased in error.

INFORMATION REGARDING THE NAME EQUALITY ACT OF 2007

The Name Equality Act of 2007 (AB 102, Chapter 567, Statutes of 2007, amended by AB 1143, Chapter 512, Statutes of 2009) allows one or both
applicants to a California marriage to elect to change the middle and/or last names by which each party wishes to be known after they are married
by entering the new name in the new name fields, as applicable, on the marriage license application. This must be done at the time the applicants
are applying for the marriage license.

Each party to the marriage may adopt any of the following last names (Family Code Section 306.5(b)(2)):

• Current last name of the other spouse.

• Last name of either spouse given at birth.
• A name combining into a single last name all or a segment of the current last name or the last name of either spouse given at birth.
• A hyphenated combination of last names.

Each party to the marriage may adopt any of the following middle names (Family Code Section 306.5 (b)(3):

• Current last name of either spouse.

• The last name of either spouse given at birth.
• A hyphenated combination of the current middle name and the current last name of the person or spouse.
• A hyphenated combination of the current middle name and the last name given at birth of the person or spouse.

NOTE: Parties to the marriage may not change their first name on the marriage license. Parties to the marriage may not add or amend this
information after the marriage license is issued unless it is a clerical error and the amendment is signed by the county clerk or his or her deputy
and one of the parties to the marriage.

Parties to the marriage are not required to change their name, nor, are they required to have the same name.

If one or both parties do not wish to identify a new name on the marriage license, the fields on the marriage license will be completed using two
single dashes. You may not change the information on the marriage license after it has been issued by the County Clerk.
The marriage certificate is used by multiple local, state, federal and private agencies, each of which have different requirements regarding what
documents are acceptable to change your name on their records following marriage. It is recommended that you contact these agencies to verify
their requirements prior to applying for your marriage license.

County Clerk staff cannot provide you information on how to complete the marriage license application as it relates to the entry of a new name or
retention of your former name on the marriage license application. For your protection, if you have any questions regarding whether you should or
should not list your new name on the marriage license application, and/or how the Name Equality Act of 2007 may affect you, please consult with a
private attorney prior to applying for your marriage license.