*This translation template is to be used for US passport/report of birth applications.

*
CERTIFICATE OF ACCEPTANCE OF MARRIAGE REPORT

DATE OF REPORT :

HUSBAND

NAME :

DATE OF BIRTH :

PERMANENT DOMICILE (HONSEKI) :

WIFE

NAME :

DATE OF BIRTH :

PERMANENT DOMICILE (HONSEKI) :

Issue # :

This is to certify the forgoing report was accepted on

Issue Date :

Title :

Name :

I certify that the foregoing is a correct translation.

Translator's signature :

Translator's Name :

Date :