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Print Form CHAMPAIGN COUNTY MARRIAGE APPLICATION AND RECORD County Partner A License Number Champaign First Name Middle Name Street and Number or R.F.D City Suffix Last Name on Birth Certificate City of Birth Date of Birth month/day/year Gender Last Name State Zip Code Birthplace State or Foreign Country Occupation Social Security Number Email Phone Number Parent s Name First Middle Last Birth Name Address State Zip Code If Parties Are Related to Each Other - Specify Relationship Race...
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