[............... (state here name of intended husband), whose place of residence is

.................; whose age is ........; and who is ............... (state here whether single,

widower, or divorced, as the case may be), and .......... (state here name of intended

wife), whose place of residence is...................; and who is (state here whether single,

widow, or divorced, as the case may be), and who are.......(state here also whether the

parties to be married are in any way related).] THE FOLLOWING INDIVIDUALS:

(STATE HERE NAME OF INTENDED HUSBAND)

(STATE HERE NAME OF INTENDED WIFE)

Given under my hand and seal of the Circuit Court for ............., [at .............] this

........... day of.................. [A.D., one thousand nine-hundred and ...............] (STATE

HERE MONTH AND YEAR)."

(2) A license shall contain:

(I) APPROPRIATE SPACES IN WHICH THE CLERK SHALL ENTER:

1. THE RELATIONSHIP OF THE PARTIES TO BE MARRIED, IF

ANY; AND

2. AS TO EACH PARTY, THE NAME, AGE, STATE IN WHICH
BORN, RESIDENCE, AND MARITAL STATUS (SINGLE, WIDOWED, OR DIVORCED); AND

3. THE SOCIAL SECURITY NUMBER OF EACH PARTY WHO
VOLUNTARILY DISCLOSES THE NUMBER; AND

5. THE SOCIAL SECURITY NUMBER OF EACH PARTY WHO
VOLUNTARILY DISCLOSES THE NUMBER; AND

(II) a statement that the license is valid only:

[(i)] 1. for 6 months from the EFFECTIVE date [it is issued] AND
TIME STATED ON THE LICENSE; and

[(ii)] 2. in the county in which it is issued.

(b) (1) Attached to a license shall be 2 certificate forms that:

(i) read, "I hereby certify that on this............day of [....................,

one thousand nine hundred and] ............. (STATE HERE MONTH AND YEAR), ........

(STATE HERE TIME), at .............. (STATE HERE LOCATION), [............... (state here

name of husband) and ............... (state here name of wife) were by me united in

marriage] in accordance with the license issued by the Clerk of the Circuit Court for

.................(STATE HERE JURISDICTION), I UNITED IN MARRIAGE THE FOLLOWING

INDIVIDUALS:

(STATE HERE NAME OF HUSBAND)
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