Fillable APPLICATION FOR CERTIFIED COPY OF A CONFIDENTIAL MARRIAGE (County of Alpine)

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APPLICATION FOR CERTIFIED COPY OF A CONFIDENTIAL MARRIAGE (County of Alpine)

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APPLICATION FOR CERTIFIED COPY OF A CONFIDENTIAL MARRIAGE CERTIFICATE
Effective January 1, 2010, California State Law, Health and Safety Code Section 103526, permits only authorized persons as
defined below to receive certified copies of marriage records.
Note: If the marriage license was not issued in ALPINE County, then the ALPINE County Clerk will not have the marriage
certificate. Please order the marriage certificate from the Recorder or County Clerk of the county where the license was
issued.
Fees: $14.00 per copy (payable to Alpine County Clerk). If no record of the marriage is found, the $14.00 fee will be
retained for searching the record (Health & Safety Code Section 103650) and a Certificate of No Record will be issued to the
applicant. Copies may be obtained in person or by mail at:
Alpine County Clerk
PO Box 158
Markleeville, CA 96120
Confidential marriage certificate:
To receive a Certified Copy I am:
†
One of the parties to the confidential marriage
†
A party entitled to receive the record as a result of a court order (include a certified copy of the court order with this
request)
Those who are not authorized by law to receive a certified copy of a confidential marriage record will receive a letter
confirming the existence of a confidential marriage pursuant to Family Code Section 511(c).
DO NOT complete the rest of this form before reading the detailed instructions on Page 3.
APPLICANT INFORMATION (PLEASE PRINT OR TYPE)
Printed Name and Signature of Person Completing Application
Today’s Date Telephone Number – Area Code First
( )
Address – Number, Street
City
State
ZIP Code
Name of Person Receiving Copies, if Different From Above
No. of Copies
Amount Enclosed
Purpose of Request
Mailing Address for Copies, If Different From Above
City
State
ZIP Code
NAMES OF BOTH PARTIES TO THE MARRIAGE (PLEASE PRINT OR TYPE)
First Name Middle Name Last Name as listed on marriage certificate
First Name
Middle Name Last Name as listed on marriage certificate
Date of Marriage – Month, Day, Year
County Where License was Issued
County of Marriage
VS 113 (01/01/10) Page 1 of 3
SWORN STATEMENT
I, _, declare under penalty of perjury under the laws of the State of California,
(Printed Name)
that I am an authorized person, as defined in California Health and Safety Code Section 103526 (c), and am eligible to receive a
certified copy of the marriage certificate of the following individual(s):
Name of Both Parties Listed on the Marriage Certificate
Your Relationship to the Parties Listed on
the Marriage Certificate
(The remaining information must be completed in the presence of a Notary Public or County Clerk staff.)
Subscribed to this day of , 20 _, at , _.
(Day) (Month) (City) (State)
(Signature of person requesting certified copy)
Note: If submitting your order by mail, you must have your signature on the Sworn Statement acknowledged
by a Notary Public using the Certificate of Acknowledgment below. If submitting your order in person, you
must sign this in the presence of
Alpine County Clerk Staff.
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
State of )
County of )
CERTIFICATE OF ACKNOWLEDGMENT
) ss
On , before me, , personally
(Insert your name and title)
appeared , who proved to me on the
basis of satisfactory evidence to be the person(s) whose name is/are subscribed to the within instrument and acknowledged to me
that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument
the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and
correct.
WITNESS my hand and official seal.
(NOTARY SEAL)
NOTARY SIGNATURE
Page 2 of 3
INSTRUCTIONS:
1. Certified copies of confidential marriage certificates are only available to the parties of that confidential
marriage. Informational copies are not available for confidential marriage certificates.
2. Complete a separate application form for each record of marriage requested.
3. Complete the Applicant Information section on the first page of this form and provide your signature
where indicated. Provide all the information you have available to identify the record of the registrant
under Marriage Certificate Information. If the information you furnish is incomplete or inaccurate, it
may be impossible to locate the record.
4. SWORN STATEMENT:
•
The authorized individual requesting the certified copy must sign the attached Sworn Statement,
declaring, under penalty of perjury, that they are eligible to receive the certified copy of the
marriage record and identify their relationship to the registrant.
•
If the application is being submitted by mail, your signature on the Sworn Statement must be
acknowledged by a Notary Public. (To locate a Notary Public, see your local yellow pages or
call your banking institution.).
•
If the application is being submitted in person at the Alpine County Clerk’s Office, the Sworn
Statement must be signed by you in the presence of the County Clerk Staff, and your
signature does not have to be acknowledged by a Notary Public. You must also provide
valid photo identification to the County Clerk Staff at the time you apply for the copy.
5. Submit $14.00 for each certified copy requested. If no record of the marriage is found, the $14.00 fee will
be retained for searching the record (as required by Health & Safety Code Section 103650) and a
Certificate of No Public Record, or a letter confirming the existence of a confidential marriage will be
issued to the applicant. Indicate the number of certified copies you wish and include the correct fee(s) in
the form of a personal check, postal or bank money order (International Money Order for out-of-country
requests) made payable to the Alpine County Clerk. Mail this application with the fee(s) and a self-
addressed stamped envelope to:
Alpine County Clerk
PO Box 158
Markleeville, CA 96120
MARRIAGE RECORD
Page 3 of
3
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APPLICATION FOR CERTIFIED COPY OF A CONFIDENTIAL MARRIAGE (County of Alpine)

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Completed 17 July 2020

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