Sec. 4. (a) An application for a marriage license must be written and verified. The application must contain the following information concerning each of the applicants:
(1) Full name.
(2) Birthplace.
(3) Residence.
(4) Age.
(5) Names of dependent children.
(6) Full name, including the maiden name of a mother, last known residence, and, if known, the place of birth of:
(A) the birth parents of the applicant if the applicant is not adopted; or
(B) the adoptive parents of the applicant if the applicant is adopted.
(7) Whether either of the applicants is a lifetime sex or violent offender, and, if an applicant is a lifetime sex or violent offender, the county and state in which the conviction was entered giving rise to the applicant's status as a lifetime sex or violent offender.
(8) A statement of facts necessary to determine whether any legal impediment to the proposed marriage exists.
(9) Except as provided in subsection (e), an acknowledgment that both applicants must sign, affirming that the applicants have received the information described in section 5 of this chapter, including a list of test sites for the human immunodeficiency virus (HIV). The acknowledgment required by this subdivision must be in the following form:
ACKNOWLEDGMENT
I acknowledge that I have received information regarding serious communicable diseases that are sexually transmitted and a list of test sites for the human immunodeficiency virus (HIV).