[About Divorce Source] Marriage Certificate Request* (State Certificate Cost: $25-$35 plus Our Processing Fee: $39.95) Questions? Call 1-800-680-9052 *You MUST complete this form on-line and click the print button on your browser. Submitting the form information via the internet is not an option because we need your signature and a photocopy of either the Certificate Holder's (Husband or Wife) Driver's License or State Issued Identification Card. Step 1. Step 2. Step 3. Complete Form, Print Form and Sign Form Photocopy Driver's License or State ID Fax to 610-770-9342 or Mail to: Certificate Processing Department, Divorce Source, Inc. P.O. Box 1580 Allentown, PA 18105-1580 PROCESSING TIME: Certificate(s) arrive to you within 3-10 business days by Express Courier service and customer signature is required by the courier. Complete, Print & Sign this Form: Husband's Full name: (First - Middle - Last) Wife's Full Name: (First - Middle - Last) Date of Marriage: ( MM/DD/YYYY ) Marriage State: Marriage City: Marriage County: Purpose of Request: Choose one... Legal Reasons Court Proceedings Identification Passport Travel Use Driver's License Marriage License Welfare Assistance Vetran's Benefits Other Other Reason for Request (if any): Relationship of Requestor: Choose one... Self Mother Father Brother Sister Husband Wife Son Daughter Legal Represenative Requestor Name (You): Mailing Address: (No PO Box, APO, AFO addresses. Street address required!) Mailing City: Mailing State: Mailing Zip: Day Time Phone: E-mail: Credit Card Number: Credt Card Type: Choose one... Visa Master Card American Express Discover Expiration Date: ( MM/YY ) Number of Copies: Choose one... 1 2 3 4 (cost of additional copies vary by state from $5 to $10) Signature Authorization Block... Signature*: __________________________________ Date: ________________ I authorize Divorce Source, Inc. to process and obtain this marriage certificate. I also authorize Divorce Source, Inc. and the appropriate state agency to charge the above credit card for the appropriate amount. I also understand that all sales are final and that delays in processing may occur due to volume and workload of the Department of State. I also acknowledge that the above information is correct and accurate to the best of my knowledge and that the Department of State may contact me for further information regarding this request. *You MUST provide a signature above and attach a photocopy of the Certificate Holder's (Husband or Wife) Driver's License or State Issued Identification Card to this form. Questions: 1-800-680-9052 Fax Order: 610-770-9342 Mail Order: Divorce Source, Inc - P.O. Box 1580 - Allentown, PA 18105-1580 Processing Time: Certificate(s) arrive to you within 3-10 business days by Express Courier service and customer signature is required by the courier.

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