Ill. Admin. Code tit. 77, § 500.APPENDIX C
| STATE OF ILLINOIS | STATE FILE NUMBER | ||||||||||||||||||||||||||||||||||||||||
| MARRIAGE APPLICATION AND RECORD | |||||||||||||||||||||||||||||||||||||||||
| TYPE / PRINT IN PERMANENT BLACK INK | County | License Number | |||||||||||||||||||||||||||||||||||||||
| 1. Groom – Name | First | Middle | Last | ||||||||||||||||||||||||||||||||||||||
| 2a. Residence – Street and Number or R.F.D. | 2b. City | 2c. County | 2d. State | ||||||||||||||||||||||||||||||||||||||
| GROOM | 3a. Date of Birth (Month, Day, Year) | 3b. Age | 3c. Birthplace (State or Foreign Country) | 4. Social Security Number | 5. Usual Occupation | ||||||||||||||||||||||||||||||||||||
| Printed by the Authority of the State of Illinois | 6a. Father – Name | 6b. Address | 6c. Birthplace (State or Foreign Country) | ||||||||||||||||||||||||||||||||||||||
| 7a. Mother – Maiden Name | 7b. Address | 7c. Birthplace (State or Foreign Country) | |||||||||||||||||||||||||||||||||||||||
| 8a. Bride – Name | First | Middle | Last | 8b. Maiden Name (If Different) | |||||||||||||||||||||||||||||||||||||
| 9a. Residence – Street and Number or R.F.D. | 9b. City | 9c. County | 9d. State | ||||||||||||||||||||||||||||||||||||||
| BRIDE | 10a. Date of Birth (Month, Day, Year) | 10b. Age | 10c. Birthplace (State or Foreign Country) | 11. Social Security Number | 12. Usual Occupation | ||||||||||||||||||||||||||||||||||||
| 13a. Father – Name | 13b. Address | 13c. Birthplace (State or Foreign Country | |||||||||||||||||||||||||||||||||||||||
| 14a. Mother – Maiden Name | 14b. Address | 14c. Birthplace (State or Foreign Country | |||||||||||||||||||||||||||||||||||||||
| 15. If Parties Are Related To Each Other – Specify Relationship | 16. This License Effective On – | ||||||||||||||||||||||||||||||||||||||||
| WE HEREBY CERTIFY THAT THE INFORMATION GIVEN IN THIS APPLICATION IS TRUE TO THE BEST OF OUR KNOWLEDGE, THAT WE ARE FREE TO INTERMARRY UNDER THE LAWS OF THIS STATE AND THE LAWS OF THE JURISDICTION WHERE WE RESIDE AND WE ARE THE IDENTICAL PERSONS NAMED IN THE ACCOMPANYING PHYSICIAN'S CERTIFICATES. | |||||||||||||||||||||||||||||||||||||||||
| AFFIDAVIT | 17. Groom (Sign Full Name) ► | 18. Bride (Sign Full Name) ► | |||||||||||||||||||||||||||||||||||||||
| 19. Subscribed and Sworn To Before Me On: | 20. Signature of County Clerk | By | Deputy | ||||||||||||||||||||||||||||||||||||||
| 21. Date of Marriage (Month, Day, Year) | 22. Place of Marriage (City, Vill., or Town. If Rural, Give Twp. Name or Road Dist.) | 23. Type of Ceremony (Religious or Civil) (Specify) | |||||||||||||||||||||||||||||||||||||||
| MARRIAGE RECORD | 24. Name of Officiant | 25. Title | |||||||||||||||||||||||||||||||||||||||
| 26. Date Recorded (Month, Day, Year) | 27. Signature of County Clerk | By | Deputy | ||||||||||||||||||||||||||||||||||||||
| VR 600 (1989) | ILLINOIS DEPARTMENT OF PUBLIC HEALTH – OFFICE OF VITAL RECORDS | (BASED ON 1989 U.S. STANDARD FORM) | |||||||||||||||||||||||||||||||||||||||
| INFORMATION FOR STATISTICAL PURPOSES ONLY | |||||||||||||||||||||||||||||||||||||||||
| Race | Education (Specify Highest Grade Completed) | Number of This Marriage | If Previously Married – Last Marriage Ended by Death, Dissolution or Invalidity of Marriage | ||||||||||||||||||||||||||||||||||||||
| SPECIFY (e.g. WHITE, BLACK, AMERICAN INDIAN, ETC.) | ELEMENTARY OR SECONDARY (0-12) | COLLEGE (1-4 OR 5 +) | FIRST-SECOND ETC. (SPECIFY) | SPECIFY HOW | SPECIFY WHEN (MONTH, DAY, YEAR) | SPECIFY WHERE-COUNTY & STATE | |||||||||||||||||||||||||||||||||||
| GROOM | 28. | 29. | 30a. | 30b. | 30c. | 30d. | |||||||||||||||||||||||||||||||||||
| BRIDE | 31. | 32. | 33a. | 33b. | 33c. | 33d. | |||||||||||||||||||||||||||||||||||
| 34. Of Hispanic Origin? | 34a. | □ No | □ Yes | 34b. | □ No | □ Yes | |||||||||||||||||||||||||||||||||||
| (Specify No or Yes – If yes, specify | GROOM | BRIDE | |||||||||||||||||||||||||||||||||||||||
| Cuban, Mexican, Puerto Rican, etc.) | Specify: | Specify: | |||||||||||||||||||||||||||||||||||||||
IL 482-0010
AFFIDAVIT OF CONSENT OF PARENT OR GUARDIAN FOR MARRIAGE OF MINOR
STATE OF ILLINOIS SS.
COUNTY______________________
_________________________________________________ AND _________________________________________________
BEING DULY SWORN, DEPOSES AND SAYS THAT THEY ARE THE PARENTS OR GUARDIAN OF_______________________,
A MINOR, AND GIVE THEIR CONSENT TO THE MARRIAGE OF SAID MINOR TO___________________________________, AND
AFFIANTS FURTHER SAY THAT THE SAID MINOR WAS BORN__________________, 19____.
| SIGNATURE OF FATHER OR GUARDIAN | |
| SIGNATURE OF MOTHER OR GUARDIAN |
SUBSCRIBED AND SWORN TO BEFORE ME THIS ______ DAY OF ____________________________, 19______.
| SIGNATURE OF COUNTY CLERK OR NOTARY |
STATE OF ILLINOIS SS.
COUNTY______________________
_________________________________________________ AND __________________________________________________
BEING DULY SWORN, DEPOSES AND SAYS THAT THEY ARE THE PARENTS OR GUARDIAN OF_______________________,
A MINOR, AND GIVE THEIR CONSENT TO THE MARRIAGE OF SAID MINOR TO_________________________________, AND
AFFIANTS FURTHER SAY THAT THE SAID MINOR WAS BORN__________________, 19____.
| SIGNATURE OF FATHER OR GUARDIAN | |
| SIGNATURE OF MOTHER OR GUARDIAN |
SUBSCRIBED AND SWORN TO BEFORE ME THIS ______ DAY OF ____________________________, 19______.
| SIGNATURE OF COUNTY CLERK OR NOTARY |
(Source: Added at 15 Ill. Reg. 11706, effective August 1, 1991)