Affidavit of Absent Applicant and Application For Marriage License (ONLY for INCARCERATED and MILITARY)

STATE OF MISSOURI AFFIDAVIT OF ABSENT APPLICANT
AND APPLICATION FORMARRIAGE LICENSE(Rev 7-14-15)
[NOTE: THIS AFFIDAVIT MUST BE DATED SIX MONTHS OR LESS PRIOR TO THE
PRESENTATION OF THE COMPLETED APPLICATION TO THE RECORDER OF DEEDS.]

STATE OF__________________________)
) SS
COUNTY OF ___________________ )

_______________________________________________________________________________(Absent Applicant),

first being duly sworn on this _____ day of _______________________________, 20___, on his/her oath states:

(Please print all information)

Name (First, Middle, Last) ___________________________________________________________________________

Social Security No: __________________________(If do not have a Social Security Number, check here __________ )

Please check one:___ Male_____Female

State birth name if different: _______________________________________________________________

Age Last Birthday:_____ Date of Birth (Month, Day, Year): _______________________________________________

o (NOTE: You must be eighteen years of age in order to submit this Affidavit.)

Birthplace (State or Country)_________________________________________________________________________

Residence (City, Town or Location)___________________________________________________________________

County__________________________State____________________________________ Zip ______________

Number of this Marriage:______

If previously married, last marriage ended by___Death; ___Dissolution;___Annulment

Date last marriage ended: Month ______________________________ Year _________

Race: ___White; ___Black; ___ American Indian; ___Other (Specify) _______________________________________

Education (Specify highest grade completed)K-12 ______College(No. of years completed) _____________________

I affirm I am over the age of 18 years of age, am legally competent to make an affidavit and do so on the basis of

personal knowledge. and have capacity to enter into a marriage contract.

I affirm this proposed marriage is NOT a marriage between parent and child, between grandparent and grandchild of any

degree, between brother and sister of the half or the whole blood, between uncle and niece, between aunt and nephew or

between first cousins.

I also affirm that I have not been adjudged incapacitated.

I have attached a copy of one or more government issued identifications, which contain my photo.(If no photo is

available/attached, check here ________)

I affirm I am making this Affidavit and Application for Marriage License to marry the following person:

Name (First, Middle, Last): __________________________________________________________________________

I am unable to appear in the presence of a Recorder of Deeds in the State of Missouri, for the reason selected below,

which is confirmed by the Verification attached to this affidavit:

(Select one that applies)

□I am currently incarcerated at_____________________________________________________________________; or

□I am currently on active military duty

at______________________________________________________________________________________;or

□ I have been diagnosed with a significant disability subject to the Americans with Disabilities Act .

I, ________________________________________________________________ (Absent Applicant) solemnly swear

(or Affirm) that the information I have given in this Affidavit of Absent Applicant and completed Application for Marriage

License to obtain a marriage license for the State of Missouri is true and correct.

Signature of Absent Applicant ___________________________________________

(Print Name)_________________________________________________________

State of __________________ )
)ss
County of ____________________ )

Subscribed and sworn to before me by ____________________________________________, who personally appeared

before me and is known to me to be the person described in and who executed the foregoing Affidavit of Absent Applicant and

Application for Marriage License and acknowledged that the facts set forth herein are true and correct to the best of his/her

knowledge and information and that he/she executed the Affidavit of Absent Applicant and Applicant for Marriage License as

his/her free act and deed.

In Witness Whereof, I have hereunto set my hand and affixed my official seal on this ________ day of

_________________________________20____.

(Seal) Signature_____________________________________________

(Print name)___________________________________________

Title_________________________________________________

My Commission expires:___________________________
 *****************************************************************

VERIFICATION OF INCARCERATED PERSON

I___________________________________________________________________(Professional, Official or Designee)

am currently over the age of 18 years of age; am legally competent to make an affidavit; and do so on the basis of personal

knowledge.

I hereby certify that I am the professional or official (or the designee of such person) who directs the operations of the

following jail or prison:____________________________________________________________________________________

and that ________________________________________________________________________(Name of Incarcerated Person)

is the person who executed this Affidavit of Absent Applicant and Application for Marriage License and is currently incarcerated

within the said institution.

I also certify that the social security number listed by_____________________________________________________

__________________________________(Name of Incarcerated Person) on the Affidavit of Absent Applicant and Application

for Marriage License is consistent with the records maintained by the foregoing institution.

Signature_________________________________________________
(Print name beneath signature)

Title_____________________________________________________

Date_____________________________
 *************************************************************************************
VERIFICATION OF PERSON ON ACTIVE MILITARY DUTY

I___________________________________________________________________(Commanding Officer or Designee)

hereby certify that I am the Commanding Officer (or the commander’s designee) of _____________________________________

____________________________________________(Name of Military Person/Applicant) who is located at:

____________________________________________________________________________________________ [military unit

designation and location], am currently over the age of 18 years of age; am legally competent to make an affidavit; and do so on

the basis of personal knowledge.

I certify that _______________________________________________________________ (Name of Absent Applicant)

is the person who executed this Affidavit of Absent Applicant and Application for Marriage License and is currently stationed at

_________________________________________________________________________ and is unable to appearbefore the

Recorder of Deeds or the Recorder’s deputy for _____________________________________ County, Missouri.

I also certify that the social security number listed by ________________________________________

__________________________________________________(Name of Absent Applicant) on the Affidavit of Absent Applicant

and Application for Marriage License is consistent with the records maintained by the foregoing military.

Signature_________________________________________________
(Print name beneath signature)

Title/Rank or Grade __________________________________________

Date_____________________________
 **********************************************************************
VERIFICATION OF PERSON DIAGNOSED PURSUANT TO THE
AMERICANS WITH DISABILITIES ACT

I, ______________________________________________________________ being first duly sworn upon my oath,

state the following:

I am currently over the age of 18 years of age; am legally competent to make an affidavit; and do so on the basis of

personal knowledge.

I am a(n) _________________________________________ (physician [MD or DO], chiropractor, nurse [LPN or RN],

physical therapist, occupational therapist, psychologist, professional counselor, or clinical social worker) who holds a valid

license for the state of ____________________________________________________to practice in such field.Based on my

education, training, and experience and as a result of my evaluation of _________________________________________

_______________________(Name of Absent Applicant), who has been diagnosed with a significant disability that prevents

him/her from appearing before the Recorder of Deeds or the Recorder’s deputy for _____________________________________

County, Missouri to execute a marriage license application in the presence of such official.

To the best of my personal knowledge, the applicant has not been adjudged incapacitated.

Signature____________________________________________________
(Print name beneath signature)

Title________________________________________________________

State License No. ____________________________________________

Date_____________________________