(a) The county clerk shall furnish the application form as prescribed by the bureau of vital statistics.
(b) The application form must contain:
(1) a heading entitled “Application for Marriage License, ____________ County, Texas”;
(2) spaces for each applicant’s full name, including the woman’s maiden surname, address, social security number, if any, date of birth, and place of birth, including city, county, and state;
(3) a space for indicating the document tendered by each applicant as proof of identity and age;
(4) spaces for indicating whether each applicant has been divorced within the last 30 days;
(5) printed boxes for each applicant to check “true” or “false” in response to the following statement: “I am not presently married and the other applicant is not presently married.”;
(6) printed boxes for each applicant to check “true” or “false” in response to the following statement: “The other applicant is not related to me as:
(A) an ancestor or descendant, by blood or adoption;
(B) a brother or sister, of the whole or half blood or by adoption;
(C) a parent’s brother or sister, of the whole or half blood or by adoption;
(D) a son or daughter of a brother or sister, of the whole or half blood or by adoption;
(E) a current or former stepchild or stepparent; or
(F) a son or daughter of a parent’s brother or sister, of the whole or half blood or by adoption.”;
(7) printed boxes for each applicant to check “true” or “false” in response to the following statement: “I am not presently delinquent in the payment of court-ordered child support.”;
(8) a printed oath reading: “I SOLEMNLY SWEAR (OR AFFIRM) THAT THE INFORMATION I HAVE GIVEN IN THIS APPLICATION IS CORRECT.”;
(9) spaces immediately below the printed oath for the applicants’ signatures;
(10) a certificate of the county clerk that:
(A) each applicant made the oath and the date and place that it was made; or
(B) an applicant did not appear personally but the prerequisites for the license have been fulfilled as provided by this chapter;
(11) spaces for indicating the date of the marriage and the county in which the marriage is performed;
(12) a space for the address to which the applicants desire the completed license to be mailed; and
(13) a printed box for each applicant to check indicating that the applicant wishes to make a voluntary contribution of $5 to promote healthy early childhood by supporting the Texas Home Visiting Program administered by the Office of Early Childhood Coordination of the Health and Human Services Commission.

(c) An applicant commits an offense if the applicant knowingly provides false information under Subsection (b)(1), (2), (3), or (4). An offense under this subsection is a Class C misdemeanor.
(d) An applicant commits an offense if the applicant knowingly provides false information under Subsection (b)(5) or (6). An offense under this subsection is a Class A misdemeanor.