Missouri Department of Health & Senior Services - Jefferson City Marriage Statement Print this form, complete it and fax it to 8665501851

Husband's Name ______________________________________________________________________   (first middle last)   Wife's Maiden Name ________________________________________________________________   (first middle last) Date of Marriage ___________________________ City ____________________________ State_______ Relationship:   Self  Mother  Father  Other ________________________________ Reason for request _________________________________________ Number Of Copies _______ Ship Method: Express Courier (additional charges)  Regular Mail Ship To Name ______________________________________________________________________ Address ______________________________________________________________________ City __________________________________________ State ________ Zip _________ Phone Number __________________________________________ Email Address __________________________________ Credit Card: Visa   MasterCard    American Express   Discover Credit Card Number ______________________________________________ Expires ________ Cardholder's Signature ______________________________________________   Date ________ Applicant's Signature (if different from cardholder) _____________________________________________________   Date _____________ When making a copy of your ID to place here, enlarge and lighten it to aid identification. This will reduce the processing time.