§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.