§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:
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,
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§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:
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 ______ (1 st , 2 nd , 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 ______ (1 st , 2 nd , 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