Request to Modify Marriage License
On _________________, _________________________ & ____________________________
(
Date of application) (print Bride’s name) (print Groom’s name)
applied for a marriage license in Clay County, Florida.
After leaving the Clay County Clerk’s office with the completed Marriage License, I/we
discovered that certain information on the original Marriage License was incorrect.
The following needs to be corrected:
Item Number Incorrect Data Corrected Data
I/We am/are requesting the Clerk of the Circuit Court of Clay County to correct the Marriage
License based on the information we have provided above.
Under penalty of perjury of law, I/we swear or affirm the above information is correct to the best
of my/our knowledge.
Date: _________________________
Bride: ________________________ ______________________________
(signature) (print name)
Groom: _________________________ ______________________________
(signature) (print name)
State of Florida
County of Clay
Sworn to or affirmed and signed before me on _____________________________
by _________________________________________________________________________.
________________________________________
(Signature of Deputy Clerk or Notary Public)
____________________________________________
(Printed Name of Deputy Clerk or Notary Public)
____
_ Personally Known
_____ Produced identification
Type of identification produced _______________________
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