RECORD OF SOCIAL SECURITY NUMBERS PER ABOVE LAW

When the application for marriage license is submitted, the applicant(s)
shall provide the clerk with the social security numbers of the parties.


_______________________________________ Groom Social Security Number


_______________________________________ Bride Social Security Number


_________________________ Date



I hereby certify that the above informtion is true and correct to the 
best of my knowledge.


_______________________________________ Groom Signature


_______________________________________ Bride Signature


I hereby certify that I will record the above social security numbers
as required by the law and that they will remain confidential and not 
open for public inspection.


________________________________________Town Clerk


__________________________ Date