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Get FL DH 743A 2010

INFORMATION BELOW FOR USE BY VITAL STATISTICS ONLY NOT TO BE RECORDED STATE OF FLORIDA AFFIRMATION OF COMMON CHILD REN BORN IN FLORIDA TYPE OR PRINT INFORMATION Reset Form Marriage Application Number GROOM S NAME First Middle Last Date of Birth mm/dd/yyyy Birthplace State/Country BRIDE S NAME First Middle Last BRIDE S MAIDEN SURNAME If different In accordance with 741. 01 Florida Statutes we hereby attest that we are the parents of the following minor child ren born in the State of Florida* Name of child As appears on Birth Certificate Birth Certificate number if known Place of birth City County State Florida Florida State of Pasco Personally Known OR Produced identification Type of Identification Produced. BY OUR SIGNATURES we do hereby swear and affirm that all of the information contained herein is true and correct and may be relied upon for the issuance of a marriage license. Groom s signature Bride s signature SWORN to and subscribed before me this day of Signature of Deputy Clerk or notary Print or Type Deputy Clerk s Name or notary SEAL DH 743A 6/10. 01 Florida Statutes we hereby attest that we are the parents of the following minor child ren born in the State of Florida* Name of child As appears on Birth Certificate Birth Certificate number if known Place of birth City County State Florida Florida State of Pasco Personally Known OR Produced identification Type of Identification Produced. BY OUR SIGNATURES we do hereby swear and affirm that all of the information contained herein is true and correct and may be relied upon for the issuance of a marriage license. BY OUR SIGNATURES we do hereby swear and affirm that all of the information contained herein is true and correct and may be relied upon for the issuance of a marriage license. Groom s signature Bride s signature SWORN to and subscribed before me this day of Signature of Deputy Clerk or notary Print or Type Deputy Clerk s Name or notary SEAL DH 743A 6/10. 01 Florida Statutes we hereby attest that we are the parents of the following minor child ren born in the State of Florida* Name of child As appears on Birth Certificate Birth Certificate number if known Place of birth City County State Florida Florida State of Pasco Personally Known OR Produced identification Type of Identification Produced. BY OUR SIGNATURES we do hereby swear and affirm that all of the information contained herein is true and correct and may be relied upon for the issuance of a marriage license. Groom s signature Bride s signature SWORN to and subscribed before me this day of Signature of Deputy Clerk or notary Print or Type Deputy Clerk s Name or notary SEAL DH 743A 6/10. .

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