1. society
2. social institution
3. marriage

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Intention No.
The Commonwealth of Massachusetts
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DEPARTMENT OF PUBLIC HEALTH
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REGISTRY OF VITAL RECORDS AND STATISTICS
124
NOTICE OF INTENTION OF MARRIAGE
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The following notice of intention of marriage is hereby given in compliance with law.
20
1.
MASSACHUSETTS
2. TO THE CLERK OF
PARTY B( Please Print)
PARTY A( Please Print)
3. PRESENT NAME:( First, Middle, Last)
11. PRESENT NAME:( First, Middle, Last)
3A. SURNAME TO BE USED AFTER MARRIAGE:
1 1A. SURNAME TO BE USED AFTER MARRIAGE:
13. OCCUPATION:
5. OCCUPATION:
14. RESIDENCE:
6. RESIDENCE:
Number
City/ Town,
and
Number and Street)
Street)
State/ Country,
7A. Status
7. THIS MARRIAGE
of
Zip
last
Code)
2nd
3`
d):
Void
Void,
by
If void,
7B.
Am/ was
City/Town, State/ Country, Zip Code)
Widowed
Divorced
or annulled
by
1St
law
at
Civil Union
so,
d):
Void, under former GL c. 207/§ 11 or
by operation of law at time of marriage
207/§ 11
If void, please provide clerk with evidence( see reverse)
Domestic
15B. Am/ was
Partnership
member of:
Civil Union
Yes
15C. If so, dissolved?
No
8. BIRTHPLACE: ( City/ Town)
Yes
16. BIRTHPLACE: ( City/ Town)
State/ Country)
Surname
of
birth
or adoption)
17. NAME MOTHER/ PARENT(
10. NAME FATHER/ PARENT(
First, Middle, Last) (
Surname
of
birth
or adoption)
18. NAME FATHER/ PARENT( First,
22. SEX
Female
Male
yes,
by
blood
or marriage
to
Party
23. SEX
B?
25. RELATED
No
Yes
Male
by blood
No
(
First, Middle, Last) (
9. NAME MOTHER/PARENT(
If
Domestic Partnership
State/ Country)
dissolved?
24. RELATED
Divorced
Void or annulled by court order
or
c.
State/ Country)
7C. If
3`
time of marriage
former GL
under
operation of
2nd
court order
please provide clerk with evidence( see reverse)
member of:
15A. Status of last marriage
15. THIS MARRIAGE
marriage
Widowed
1s`
12A. AGE:
12. DATE OF BIRTH( Month, Day, Year)
4A. AGE:
4. DATE OF BIRTH:( Month,Day, Year)
State/ Country)
Surname of birth or adoption)
First, Middle, Last) (
Middle, Last) (
Surname of birth or adoption)
Female
or marriage
to
Party A?
Yes
No
If yes, how?
how?
PENALTY: MG.L.
c. 207§
52"...
whoever falsely swears or affirms in making any statement required... shall be punished by a fine..."
I have reviewed a list of impediments to marriage and hereby state that there is an absence of any legal impediment to this marriage
and do hereby depose and say that all of the statements as set forth in the above notice whereof I could have knowledge are true
and are made under the penalties of perjury( M.G.L. c. 4§ 6, Rule 6 General Laws).
Party
A( Signature)
Subscribed
and sworn
Party B( Signature)
to, before
me,
day
this
20
of
Registrar, Clerk, or Assistant Clerk designated to administer oaths:
Marriage Certificate Issued:
20
Not Valid After:
20
60 days from date intention is filed. M.G. L. c. 207§ 20)
Form R203- 08
Name of City or Town:
Intention Number:
76__
tiar-
The Commonwealth of Massachusetts
Department of Public Health
Registry of Vital Records and Statistics
Supplement To Notice Of Intention Of Marriage
Chapter 64, Acts of 1998, requires that every couple filing an application to marry in Massachusetts provide
the following information. All information on this form must be completed prior to the issuance of a marriage
license in Massachusetts.
Complete one column for each person intending to marry.
Party
Present
name as
First
it
A
appears on
Party B
the Intention:
Middle
Present name as it appears on the Intention:
Last
First
Residence:
Residence:
Number
Number and Street
and
Street
City/ Town
Social
If
a
State/ Country
Security
SSN has
example:
Number:
never
Does
ZIP Code
City/ Town
Middle
Last
State/ Country
ZIP Code
Social Security Number:
been issued, specify reason below
in the United States).
not reside
If a SSN has never been issued, specify reason below
example: Does not reside in the United States).
We state that all of the information given above is true and we understand that all statements are made
under the penalties ofperjury.
Signature
Date Signed
Signature
Date Signed
The Supplement to the Notice of Intention of Marriage is NOT a public record. No copy will be maintained in the
office of the city or town clerk.
The original form will be forwarded to the State Registry of Vital Records and
Statistics. The information in the supplement under statute may be made available for the purposes of child
support enforcement and to other such state or federal agencies as may be required by state or federal law.
PRINT OR TYPE LEGIBLY IN BLACK INK
R208- 08
CERTIFICATE EXPIRATION DATE
INTENTION NO.:
MARRIAGE WORKSHEET
NAME PARTY A :
FEMALE
MALE
NAME PARTY B:
FEMALE
MALE
PLANNED DATE OF MARRIAGE:
PLANNED PLACE OF MARRIAGE:
Facility Name
Address— Street and Number
City
Zip Code
CURRENT TELEPHONE NUMBER:
IF YOU NEED TO BE CONTACTED AFTER MARRIAGE, WHAT IS YOUR PLANNED ADDRESS
AFTER THE MARRIAGE:
Street
and
Number
City
State
Zip Code
TELEPHONE AFTER MARRIAGE:
NAME OF OFFICIANT:
ADDRESS OF OFFICIANT :
Address— Street and Number
City
State
Zip Code
If the officiant is from another state, he or she must apply for and receive a commission from the Secretary of
State before the marriage takes place. The Commission may be obtained from:
Secretary of State, Commissions Division
floor
Building—
McCormack
17th
1 Ashburton Place
Boston, MA 02108
617) 727- 2836
RECEIVED
AGE ORDER
COURT WAIVER
COMMISSION
YES
NO
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0
0
0
0
NOT APPLICABLE
0
cr
1
COMMONWEALTH
1mi
OF MASSACHUSETTS
ONE DAY MARRIAGE DESIGNATION INSTRUCTIONS
1)
Applications MUST be received 6 weeks prior to the date of the wedding.
2)
Applicants are allowed only ONE DESIGNATION PER CALENDAR YEAR**
3)
Completed applications are to be submitted WITH a $ 25 registration fee made payable to the
Commonwealth ofMassachusetts. This fee can be paid by anyone. Applications approved by
Governor Mitt Romney will be forwarded to the Secretary of State's Office for processing.
APPLICATIONS THAT ARE RECEIVED WITHOUT THE REQUISITE CHECK WILL BE
CONSIDERED INCOMPLETE AND WILL NOT BE PROCESSED.
3)
The names of the applicant, Party A and Party B must be typed or printed as you wish them to
appear on the certificate that will be issued by the Secretary of State' s Office. This information
must coincide with the names printed on the marriage certificate. Illegible applications will
cause a delay in processing the application.
4)
A letter of reference stating the applicant's high standard of character is requiredfor all
applicants.' The letter of reference can be written by anyone, except Party A or Party B.
Applications will not be processed without a letter of reference.**
5)
The
Secretary
of State' s Office
will
then issue a
Certificate of Solemnization.
The married
parties must turn in this certificate to their town hall. PLEASE BE ADVISED THAT IF THERE
IS A CHANGE IN THE LOCATION OF THE MARRIAGE AND/ OR A CHANGE IN THE DATE
OF THE MARRIAGE, YOU WILL NEED TO SUBMIT A NEW APPLICATION
Except Judges &
members
of the Legislature
COMMONWEALTH OF MASSACHUSETTS
One Day Marriage Designation Application
Validfor all applicants who reside in Massachusetts andfor out-of-state applicants who are
NOT court appointed officers or clergy members.
TO HIS EXCELLENCY THE GOVERNOR
I hereby petitionfor the designation to solemnize a marriage on a particular datefor the following reason:
Please Print or Type Clearly and Accurately
Names will appear on the certificate as they appear on the application
APPLICANT' S INFORMATION
Check here if you are a Judge or Justice:
Name:
Street:
City/ Town:
Zip Code:
Date ofBirth:
State:
Phone:
Have
you ever
Party A
been
convicted
of a
NO
crime?
YES-•
Please supply a typed letter of explanation.
Party B Information
Information
Name:
Name:
Street:
Street:
City/ Town:
City/ Town:
State:
Zip
State:
Code:
Zip Code:
Phone:
Phone:
Date of Birth.:
Date ofBirth:
City/ Town of Wedding Location:
Date bfProposed Marriage:
APPLICATIONS THAT DO NOT CONTAIN THE REQUISITE CHECK AND LETTER OF REFERENCE WILL
BE CONSIDERED INCOMPLETE AND WILL NOT BE PROCESSED( Please initial here)
ALL STATEMENTS MADE UNDER THE PENALITIES OF PERJURY. (
CHAPTER 187, Acts of1926)
Date
SIGNATURE OF APPLICANT::
Return
completed application
to:.
OFFICE OF THE GOVERNOR
STATE HOUSE, ROOM 271M
BOSTON, MASSACHUSETTS 02133
ATTN: APPOINTMENTS OFFICE
Office of the Governor • State House • Room 271M• Boston, Massachusetts 02133 •( 617) 725- 4055