LA Rev Stat § 9:223 (2021)
2021 Louisiana Laws|Revised Statutes|Title 9 - Civil Code-Ancillaries|§223. Form

RS 223 - Form   A. An application for a marriage license shall be made on a form provided by Subsection B of this Section.  B. The application form shall be as follows:   Application for Marriage __________________(Parish), State of Louisiana Date of Application: Hour of Application:    GROOM  Last Name of Groom  First Name of Groom  Middle/Second Name of Groom       Address   Is residence inside city limits? ☐ Yes ☐ No  Parish/County  State    Race  Date of Birth (month-day-year)  State of Birth    Father's Name  State of Birth  Mother's Maiden Name  State of Birth    BRIDE  Last Name of Bride  First Name of Bride  Middle/Second Name of Bride  Maiden Name of Bride    Address   Is residence inside city limits? ☐ Yes ☐ No  Parish/County  State    Race  Date of Birth (month-day-year)  State of Birth    Father's Name  State of Birth  Mother's Maiden Name  State of Birth    Covenant Marriage  Covenant Marriage☐ Yes☐ NoIf yes, complete the following:  We, ___________________________ and _____________________________ do hereby declare our intent to contract a Covenant Marriage and, accordingly, have executed a declaration of intent attached hereto.    Groom  Has the groom been formerly married?_________ How many times?________  Are you divorced ________?     Bride  Has the bride been formerly married?_________ How many times?________  Are you divorced ________?     SSN  Grooms's Social Security Number  Bride's Social Security Number     I ___________________________ (print name of groom) do swear or affirm that the information contained in this application for marriage is true and correct. I further swear or affirm that this is my ______ (1st, 2nd, etc. number) marriage but that I am not currently married to anyone else, and that I am free to marry under the laws of the state of Louisiana. I further understand and acknowledge that giving any false information or false statement in this application of marriage shall constitute the crime of filing a false public record in violation of the Louisiana Criminal Code (R.S. 14:133).   ____________________________ Signature of Groom Sworn to and subscribed before me this ________ day of __________________, 20___.  ___________________ Notary Public/Deputy Clerk/Deputy Registrar   I ___________________________ (print name of bride) do swear or affirm that the information contained in this application for marriage is true and correct. I further swear or affirm that this is my ______ (1st, 2nd, etc. number) marriage but that I am not currently married to anyone else, and that I am free to marry under the laws of the state of Louisiana. I further understand and acknowledge that giving any false information or false statement in this application of marriage shall constitute the crime of filing a false public record in violation of the Louisiana Criminal Code (R.S. 14:133).   ____________________________ Signature of Bride Sworn to and subscribed before me this ________ day of __________________, 20___.  ___________________ Notary Public/Deputy Clerk/Deputy Registrar      Acts 1987, No. 886, §3, eff. Jan. 1, 1988; Acts 2015, No. 436, §1, eff. Jan. 1, 2016.