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FORM V.S. 18 (2014) CLERK OF COURT MONTANA MARRIAGE APPLICATION STATE FILE NUMBER MARRIAGE LICENSE NUMBER COUNTY DATE LICENSE ISSUED (Month, Day, Year) SPOUSE 1 SPOUSE 1-NAME First Middle Last MAIDEN SURNAME (if Different) SOCIAL SECURITY NO. RESIDENCE – State & Zip Code COUNTY STREET & NUMBER, CITY, TOWN OR LOCATION (City, County and State or Country) DATE OF BIRTH (Month, Day, Year) AGE FATHER'S NAME (First, Middle, Last) ADDRESS (City & State) (State or Foreign Country) MOTHER'S NAME (First, Middle, Maiden Surname) ADDRESS (If Different) (State or Foreign Country) RACE-American Indian, Black, White, etc. (Specify) SEX EDUCATION (Specify only highest Grade completed) Elementary – Secondary: (0-12) College: (1,2,3,4, or Number of this marriage First, Second, Etc. (Specify) Previous Marriage Terminated by Name of Spouse (First and Original Surname) Place of dissolution or death (County and State) Date of dissolution or death (Month, Day, Year) SPOUSE 2 SPOUSE 2-NAME First Middle Last MAIDEN SURNAME (if Different) SOCIAL SECURITY NO. RESIDENCE – State & Zip Code COUNTY STREET & NUMBER, CITY, TOWN OR LOCATION (City, County and State or Country) DATE OF BIRTH (Month, Day, Year) AGE FATHER'S NAME (First, Middle, Last) ADDRESS (City & State) (State or Foreign Country) MOTHER'S NAME (First, Middle, Maiden Surname) ADDRESS (If Different) (State or Foreign Country) RACE-American Indian, Black, White, etc. (Specify) SEX EDUCATION (Specify only highest Grade completed) Elementary – Secondary: (0-12) College: (1,2,3,4, or Number of this marriage First, Second, Etc. (Specify) Previous Marriage Terminated by Name of Spouse (First and Original Surname) Place of dissolution or death (County and State) Date of dissolution or death (Month, Day, Year) OFFICIANT DATE OF MARRIAGE (Month, Day, Year) PLACE OF MARRIAGE (County) OFFICIANT RELIGIOUS OR CIVIL OFFICIAL (Specify) LOCAL OFFICIAL MAKING REPORT TO STATE HEALTH DEPARTMENT (Signature and Title) DATE RECEIVED BY LOCAL OFFICIAL (Month, Day, Year) LEGAL INFORMATION AND SIGNATURES ARE THE PARTIES RELATED? RELATIONSHIP EITHER PARTY UNDER THE INFLUENCE OF INTOXICATING LIQUOR OR NARCOTIC DRUGS? PRIOR APPLICATION REJECTED? REASON AND DATE FUTURE ADDRESS – STREET & NUMBER, CITY, TOWN OR LOCATION STATE & ZIP CODE TELEPHONE NUMBER WE HEREBY CERTIFY THAT THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF OUR KNOWLEDGE AND BELIEF AND THAT WE ARE FREE TO MARRY UNDER THE LAWS OF THIS STATE SPOUSE 1 SIGNATURE SPOUSE 2 SIGNATURE SUBSCRIBED AND SWORN TO BEFORE ME THIS day of CLERK OF COURT BY Deputy PROOF OF AGE ☐ BIRTH CERTIFICATE ☐ DRIVER'S LICENSE ☐ OTHER (Specify) PERMISSION GRANTED PURSUANT TO 40-1-213 M.C.A. (Underage) Date District Judge