County ___________________

)

I, ______________________________, being first duly sworn, on oath, depose and say that I am the (Father/Mother/Guardian) and have legal and actual custody of __________________________, _____ years of age, and do give by consent to (his/her) marriage to ____________________________, and request the issuance of a marriage license to them.

_________________________

Subscribed in my presence and sworn to before me this _____ day of ____________________, _____.

_________________________

(seal)

(Notary Public)