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 ______ (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
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