§223. Form A. An application for a marriage license shall be made on a form provided by Subsection B of this Section. B. The application form shall be as follows:
Application for Marriage __________________(Parish), State of Louisiana Date of Application: Hour of Application:
GROOM
Last Name of Groom
First Name of Groom
Middle/Second Name of Groom
Address
Is residence inside city limits? ☐ Yes ☐ No
Parish/County
State
Race
Date of Birth (month-day-year)
State of Birth
Father's Name
State of Birth
Mother's Maiden Name
State of Birth
BRIDE
Last Name of Bride
First Name of Bride
Middle/Second Name of Bride
Maiden Name of Bride
Address
Is residence inside city limits? ☐ Yes ☐ No
Parish/County
State
Race
Date of Birth (month-day-year)
State of Birth
Father's Name
State of Birth
Mother's Maiden Name
State of Birth
Covenant Marriage
Covenant Marriage☐ Yes☐ NoIf yes, complete the following:
We, ___________________________ and _____________________________ do hereby declare our intent to contract a Covenant Marriage and, accordingly, have executed a declaration of intent attached hereto.
Groom
Has the groom been formerly married?_________ How many times?________
Are you divorced ________?
Bride
Has the bride been formerly married?_________ How many times?________
Are you divorced ________?
SSN
Grooms's Social Security Number
Bride's Social Security Number
I ___________________________ (print name of groom) do swear or affirm that the information contained in this application for marriage is true and correct. I further swear or affirm that this is my ______ (1st, 2nd, etc. number) marriage but that I am not currently married to anyone else, and that I am free to marry under the laws of the state of Louisiana. I further understand and acknowledge that giving any false information or false statement in this application of marriage shall constitute the crime of filing a false public record in violation of the Louisiana Criminal Code (R.S. 14:133). ____________________________ Signature of Groom Sworn to and subscribed before me this ________ day of __________________, 20___.
___________________ Notary Public/Deputy Clerk/Deputy Registrar
I ___________________________ (print name of bride) do swear or affirm that the information contained in this application for marriage is true and correct. I further swear or affirm that this is my ______ (1st, 2nd, etc. number) marriage but that I am not currently married to anyone else, and that I am free to marry under the laws of the state of Louisiana. I further understand and acknowledge that giving any false information or false statement in this application of marriage shall constitute the crime of filing a false public record in violation of the Louisiana Criminal Code (R.S. 14:133). ____________________________ Signature of Bride Sworn to and subscribed before me this ________ day of __________________, 20___.
___________________ Notary Public/Deputy Clerk/Deputy Registrar
Acts 1987, No. 886, §3, eff. Jan. 1, 1988; Acts 2015, No. 436, §1, eff. Jan. 1, 2016.