Application for Marriage License

Please read before completing application

 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.
 The marriage license must be used within the State of California. 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.
 The appropriate fee may be paid in cash or by check, payable to the county clerk.
 No refunds are given for marriage licenses purchased in error.
 Please check the type of marriage license you would like to apply for:
Public 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. Since the confidential
marriage license requires the signature of a marriage officiant, they are not available to members of religious
denominations not having clergy. Certified copies of the marriage license and certificate may only be issued to the
couple. Confidential marriage licenses may not be available in all counties. 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.

INFORMATION REGARDING THE NAME EQUALITY ACT OF 2007

The Name Equality Act of 2007 (Assembly Bill 102, Chapter 567, Statutes of 2007) allows one or both applicants to a
California marriage to elect to change the middle or last names by which each party wishes to be known after they are married
by entering the new name in fields 29A thru 30C, 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 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
 Last name of either spouse given at birth
 A combination of the current middle name and the current last name of the person or spouse
 A 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 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, unless there is a clerical error.

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.

NOTE: 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.
CALIFORNIA DEPARTMENT OF PUBLIC HEALTH - VITAL RECORDS VS117Be (05/2017)
 FIRST PERSON DATA GROOM BRIDE

1A. First Name 1B. Middle Name

1C. Current Last Name 1D. Last Name at Birth (if different than box 1C.)

2. Date of Birth 3. Birthplace (U.S. State or Foreign Country) 4. # of Previous Marriages or State
Registered Domestic Partnerships

5A. Last Marriage/State Registered Domestic Partnership ended by: (check one) 5B. Date ended: (mm/dd/yyyy)
Death Dissolution (Divorce) Annulment Terminated SRDP
6. Address 7. City 8. State/Country 9. Zip Code

10A. Full Birth Name of Father/Parent (First, Middle, Last) 10B. Birthplace (U.S. State or Foreign Country)

11A. Full Birth Name of Mother/Parent (First, Middle, Last) 11B. Birthplace (U.S. State or Foreign Country)

SECOND PERSON DATA GROOM BRIDE

12A. First Name 12B. Middle Name

Emily Alicia
12C. Current Last Name 12D. Last Name at Birth (if different than box 12C.)
Hans Hans
13. Date of Birth 14. Birthplace (U.S. State or Foreign Country) 15. # of Previous Marriages or State
Registered Domestic Partnerships
1995 USA
16A. Last Marriage/State Registered Domestic Partnership ended by: (check one) 16B. Date ended: (mm/dd/yyyy)
Death Dissolution (Divorce) Annulment Terminated SRDP
17. Address 18. City 19. State/Country 20. Zip Code
86 mang Ln, Apt A Angier NC 27501
21A. Full Birth Name of Father/Parent (First, Middle, Last) 21B. Birthplace (U.S. State or Foreign Country)
Christopher john Hans USA
22A. Full Birth Name of Mother/Parent (First, Middle, Last) 22B. Birthplace (U.S. State or Foreign Country)
Olivia Mia Hans USA
If you are going to use your marriage certificate for a legal name change write your new name below. A name
change will only occur after you take the certified copy of your marriage certificate to a Social Security
Administration office. If you do not write a new name below you will need to either buy a new license before a
marriage ceremony is performed or get a court ordered name change after a marriage ceremony is performed.
See Information on Reverse Outlining Options for Changing your Name.
First – MUST BE SAME AS 1A. Middle Name Last Name
N/A Emily Alicia Nogueira
First – MUST BE SAME AS 12A. Middle Name Last Name
N/A
We, the undersigned, declare under penalty of perjury that all the information above is true and correct to the best of our
knowledge. We also declare that we have read and understood the information on the reverse side of this form.

Signature (1A—1D): __________________________________ Signature (12A—12D): __________________________________

CALIFORNIA DEPARTMENT OF PUBLIC HEALTH - VITAL RECORDS VS117Be (05/2017)