1
2County __________________________________
STATE OF IOWA
License No. ______________________________
IOWA DEPARTMENT OF PUBLIC HEALTH
Date of Application ________________________
Bureau of Health Statistics and Vital Records
Valid Date of License ______________________
APPLICATION FOR LICENSE TO MARRY IN IOWA
Type or print legibly in black or dark blue ink. Do not use all capital letters.
PARTY A
(Information to be completed by the first applicant)
Bride
Groom
Spouse
Check One (Optional)
FULL LEGAL NAME BEFORE MARRIAGE
(Include any generational suffix after last name)
First
Middle (If any)
Current Last (Surname)
Last Name Prior to ANY Marriage
FULL LEGAL NAME CHANGE ADOPTED THROUGH MARRIAGE
(Include any generational suffix after last name)
First Name After Marriage
Middle Name (If any) After Marriage
Last Name (Surname) After Marriage
State
City
County
CURRENT PLACE
OF RESIDENCE
STATE OF BIRTH
DATE OF BIRTH
GENDER
(If not United States, name of foreign country)
(Month, Day, Year)
(Optional)
Mother Father Parent
Mother Father Parent
PARTY A’S PARENT Optional
PARTY A’S PARENT Optional
Check One
Check One
Parent’s Name Prior to any Marriage
Parent’s Name Prior to any Marriage
PARTY B
(Information to be completed by the second applicant)
Bride
Groom
Spouse
Check One (Optional)
FULL LEGAL NAME BEFORE MARRIAGE
(Include any generational suffix after last name)
First
Middle (If any)
Current Last (Surname)
Last Name Prior to ANY Marriage
FULL LEGAL NAME CHANGE ADOPTED THROUGH MARRIAGE
(Include any generational suffix after last name)
First Name After Marriage
Middle Name (If any) After Marriage
Last Name (Surname) After Marriage
State
City
County
CURRENT PLACE
OF RESIDENCE
STATE OF BIRTH
DATE OF BIRTH
GENDER
(If not United States, name of foreign country)
(Month, Day, Year)
(Optional)
Mother Father Parent
Mother Father Parent
PARTY B’S PARENT Optional
PARTY B’S PARENT Optional
Check One
Check One
Parent’s Name Prior to any Marriage
Parent’s Name Prior to any Marriage
SIGNATURE NOTARY AFFIRMATION
(Each party must sign and date this form in the presence of an authorized Notary Public. Each party
must show valid U.S. government-issued identification when signing. The Notary Public completes and signs below.
PARTY A: I affirm that the information I provided above is true
PARTY B: I affirm that the information I provided above is true and
and accurate and that I intend for my legal name after marriage to
accurate and that I intend for my legal name after marriage to be as
be as stated above.
stated above.
PARTY A SIGNATURE
Date Signed
PARTY B SIGNATURE
Date Signed
State of
County of
ss
State of
County of
ss
Signed and affirmed by
Signed and affirmed by
Write name exactly as appears on I.D.
Write name exactly as appears on I.D.
Notary Public’s Signature for Party A
Date Signed
Notary Public’s Signature for Party B
Date Signed
Notary Address & Expiration
Notary Address & Expiration
N O TA R Y
N O TA R Y
S E A L
S E A L
Iowa Department of Public Health, Bureau of Health Statistics & Vital Records
Page 1 of 2
FORM #588-0224VR (Updated July 1, 2016)
County __________________________________
STATE OF IOWA
License No. ______________________________
IOWA DEPARTMENT OF PUBLIC HEALTH
Date of Application ________________________
Bureau of Health Statistics and Vital Records
Valid Date of License ______________________
APPLICATION FOR LICENSE TO MARRY IN IOWA
Type or print legibly in black or dark blue ink. Do not use all capital letters.
PARTY A
(Information to be completed by the first applicant)
Bride
Groom
Spouse
Check One (Optional)
FULL LEGAL NAME BEFORE MARRIAGE
(Include any generational suffix after last name)
First
Middle (If any)
Current Last (Surname)
Last Name Prior to ANY Marriage
FULL LEGAL NAME CHANGE ADOPTED THROUGH MARRIAGE
(Include any generational suffix after last name)
First Name After Marriage
Middle Name (If any) After Marriage
Last Name (Surname) After Marriage
State
City
County
CURRENT PLACE
OF RESIDENCE
STATE OF BIRTH
DATE OF BIRTH
GENDER
(If not United States, name of foreign country)
(Month, Day, Year)
(Optional)
Mother Father Parent
Mother Father Parent
PARTY A’S PARENT Optional
PARTY A’S PARENT Optional
Check One
Check One
Parent’s Name Prior to any Marriage
Parent’s Name Prior to any Marriage
PARTY B
(Information to be completed by the second applicant)
Bride
Groom
Spouse
Check One (Optional)
FULL LEGAL NAME BEFORE MARRIAGE
(Include any generational suffix after last name)
First
Middle (If any)
Current Last (Surname)
Last Name Prior to ANY Marriage
FULL LEGAL NAME CHANGE ADOPTED THROUGH MARRIAGE
(Include any generational suffix after last name)
First Name After Marriage
Middle Name (If any) After Marriage
Last Name (Surname) After Marriage
State
City
County
CURRENT PLACE
OF RESIDENCE
STATE OF BIRTH
DATE OF BIRTH
GENDER
(If not United States, name of foreign country)
(Month, Day, Year)
(Optional)
Mother Father Parent
Mother Father Parent
PARTY B’S PARENT Optional
PARTY B’S PARENT Optional
Check One
Check One
Parent’s Name Prior to any Marriage
Parent’s Name Prior to any Marriage
SIGNATURE NOTARY AFFIRMATION
(Each party must sign and date this form in the presence of an authorized Notary Public. Each party
must show valid U.S. government-issued identification when signing. The Notary Public completes and signs below.
PARTY A: I affirm that the information I provided above is true
PARTY B: I affirm that the information I provided above is true and
and accurate and that I intend for my legal name after marriage to
accurate and that I intend for my legal name after marriage to be as
be as stated above.
stated above.
PARTY A SIGNATURE
Date Signed
PARTY B SIGNATURE
Date Signed
State of
County of
ss
State of
County of
ss
Signed and affirmed by
Signed and affirmed by
Write name exactly as appears on I.D.
Write name exactly as appears on I.D.
Notary Public’s Signature for Party A
Date Signed
Notary Public’s Signature for Party B
Date Signed
Notary Address & Expiration
Notary Address & Expiration
N O TA R Y
N O TA R Y
S E A L
S E A L
Iowa Department of Public Health, Bureau of Health Statistics & Vital Records
Page 1 of 2
FORM #588-0224VR (Updated July 1, 2016)
AFFIDAVIT OF COMPETENT AND DISINTERESTED PERSON
as to age and qualification of the contracting parties
Type or print legibly in black or dark blue ink. Do not use all capital letters.
I, the below noted disinterested person, affirm that I am acquainted with
,
who is
years of age; and that I am acquainted with
,
who is
years of age.
I affirm that I am a lawfully competent and disinterested person and impartial to the result of this pending transaction. I further
affirm that both parties are unmarried and able to enter into a civil contract, that there is no legal disability to the marriage of said
parties, and that their marriage is to be solemnized in a ceremony performed by an authorized officiant within the State of Iowa.
NOTARY PUBLIC SIGNATURE TO AFFIDAVIT OF DISINTERESTED PERSON
Notary Public cannot serve as disinterested person.
I affirm that the information I provided above is true and accurate to the best of my knowledge.
N O TA R Y
P U B L I C ’ S
S E A L
Disinterested Person Signature
Date Signed
State of
County of
ss
Signed and affirmed in my presence by
Write name exactly as appears on I.D.
Notary Public’s Signature
Date Signed
Notary Address & Expiration
NOTICE TO APPLICANTS: PLEASE READ CAREFULLY!
•
Applicants aged 16 or 17 years old must also present a completed Consent to Marriage form for approval to a judge of the
district court in the county from which the marriage license is to be obtained. Age 15 and under may NOT marry in Iowa.
•
Pursuant to Iowa Code section 595.3A, the laws of this state affirm a party’s right to enter into this marriage and at the same time
to live within the marriage under the full protection of the laws of this state with regard to violence and abuse. Neither party to the
marriage is the property of the other. Assault, sexual abuse, and willful injury of a spouse or other family member are violations of
the laws of this state and are punishable by the state.
•
Applicants’ social security numbers are collected pursuant to Iowa Code section 595.4 and 42 USC 405(c)(2), as amended by
Section 1090(b) of Public Law 105-34. The law authorizes the Internal Revenue Service (IRS) to use social security numbers for
determining Earned Income Tax Credit compliance on income tax returns and to authorize the State Registrar to report the social
security number to the Child Support Recovery Unit.
•
The $35.00 fee must accompany this application.
•
Return this form and fee to the County Registrar of Vital Records in the county where you want your record to be filed.
•
Review the Marriage Instructions handout for more details about obtaining the certified copy of your Certificate of Marriage.
*** CONFIDENTIAL INFORMATION REQUIRED BY IOWA CODE SECTION 595.4 ***
*** ADMINISTRATIVE PURPOSES ONLY *** NOT FOR PUBLIC VIEWING, DISTRIBUTION OR PUBLICATION ***
Party A Social Security Number
Party B Social Security Number
Anticipated Ceremony Date
Anticipated Officiant
Iowa Department of Public Health, Bureau of Health Statistics & Vital Records
Page 2 of 2
FORM #588-0224VR (Updated July 1, 2016)
