| | | Parties to marriage | |
| | | [Bride or bridegroom or partner] | | [Bride or bridegroom or partner] | |
| Current first or given names(s) Current surname or family name | | | | | |
| First or given name(s) at birth (if different from above) Surname or family name at birth (if different from above) | | | | | |
| Sex | | | | | |
| Full date and year of birth | | | | | |
| Place of birth | | | | | |
| Usual occupation, profession, or job | | | | | |
| What was your last relationship (if any)? If previously married or in a civil union: | | ○ | Never been married or in a civil union | ○ | Marriage | ○ | Civil union | | ○ | Never been married or in a civil union | ○ | Marriage | ○ | Civil union | | |
(1) how did that relationship end? | ○ | By dissolution/ divorce | | ○ | Death of spouse/ partner | ○ | By dissolution/ divorce | | ○ | Death of spouse/partner |
| (2) when did that relationship end? | | [date] | | [date] | |
| | | |
| Usual residential address in full, including— • flat number (if applicable) • street number and name • suburb or rural locality • city, town, or district • country (if not New Zealand) | | | | | |
| | | Parents | |
| | | [Mother or father] | | [Mother or father] | |
| First or given name(s) Surname or family name | | | | | |
| Surname or family name at birth (if different from above) | | | | | |
| | | [Mother or father or other parent] | | [Mother or father or other parent] | |
| First or given name(s) Surname or family name | | | | | |
| Surname or family name at birth (if different from above) | | | | | |
| | | | | | |