DATA ENTRY FORM HiddenUsername FIRST PERSON DATA BRIDE GROOM 1A. FIRST NAME 1B. MIDDLE 1C. CURRENT LAST 1D. LAST NAME AT BIRTH (IF DIFFERENT THAN 1C) 2. DATE OF BIRTH (MM/DD/CCYY) 3. STATE/COUNTRY OF BIRTH 4. #PREV. MARRIAGES/SRDP 5A. LAST MARRIAGE/SRDP ENDED BY: DEATH DISSO ANNULMENT TERM SRDP N/A 5B. DATE ENDED (MM/YY/CCYY) 6. ADDRESS 7. CITY 8. STATE/COUNTRY 9. ZIP CODE 10A. FULL BIRTH NAME OF FATHER/PARENT 10B. STATE OF BIRTH (IF OUTSIDE U.S. ENTER COUNTRY) 11A. FULL BIRTH NAME OF MOTHER/PARENT 11B. STATE OF BIRTH (IF OUTSIDE U.S. ENTER COUNTRY) SECOND PERSON DATA BRIDE GROOM 12A. FIRST NAME 12B. MIDDLE 12C. CURRENT LAST 12D. LAST NAME AT BIRTH (IF DIFFERENT THAN 1C) 13. DATE OF BIRTH (MM/DD/CCYY) 14. STATE/COUNTRY OF BIRTH 15. #PREV. MARRIAGES/SRDP 16A. LAST MARRIAGE/SRDP ENDED BY: DEATH DISSO ANNULMENT TERM SRDP N/A 16B. DATE ENDED (MM/YY/CCYY) 17. ADDRESS 18. CITY 19. STATE/COUNTRY 20. ZIP CODE 21A. FULL BIRTH NAME OF FATHER/PARENT 21B. STATE OF BIRTH (IF OUTSIDE U.S. ENTER COUNTRY) 22A. FULL BIRTH NAME OF MOTHER/PARENT 22B. STATE OF BIRTH (IF OUTSIDE U.S. ENTER COUNTRY) ITEMS 26A-26D COMPLETED ONLY IF LICENSE IS ISSUED BY NOTARY PUBLIC26A. STATE OF CALIFORNIA, COUNTY OF: SUBSCRIBED AND SWORN TO (OR AFFIRMED) BEFORE ME ON THIS (ENTER DD) DAY OF (ENTER MONTH) 20___, (ENTER YY) BY CERTIFICATION OF PERSON SOLEMNIZING MARRIAGE27A. DATE OF MARRIAGE (MM/DD/CCYY) 27B. CITY OF MARRIAGE 27C. COUNTY OF MARRIAGE 28B. RELIGIOUS DENOMINATION (IF CLERGY) 28C. NAME OF PERSON SOLEMNIZING MARRIAGE (TYPE OF PRINT CLEARLY) 28A. OFFICIAL TITLE 28E. ADDRESS, CITY, STATE/COUNTRY, AND ZIP CODE NEW NAME(S) (IF ANY) 29A. FIRST-MUST BE SAME AS A1 29B. MIDDLE 29C. LAST 30A. FIRST-MUST BE SAME AS A1 30B. MIDDLE 30C. LAST
