HP PHP HA H S XIN NG K KT HN TI VIT NAM

(p dng i vi ngi Vit Nam nh c ti Hoa K)

Ngi Vit Nam nh c ti Hoa K, hi iu kin kt hn v c nguyn vng kt hn vi

cng dn Vit Nam trong nc, c th trc tip n i s qun Vit Nam ti Washington DC hay
gi qua ng bu in h s xin ng k kt hn hp php ha trc khi mang v Vit Nam lm
cc th tc tip theo.
H s ca ngi Vit nh c ti Hoa k gm:
I. H s thng thng:
1. T khai ng k kt hn (Application for Marriage Registration). Nhiu tnh Vit
Nam yu cu phi dng ng mu n do tnh in v pht hnh. Nu trong nc gi mu
n ny sang, th qu v dng mu n . Mu n song ng i s qun nh km l
to iu kin thun li cho qu v. Nu dng mu ny, ngh qu v dn hnh, khai phn
ca mnh, k tn, v ghi y h tn. trng ct ca ngi Vit Nam.
2. Bn tuyn th c thn (Affidavit of Single Status) theo mu song ng nh km.
3. Giy chng nhn khng c h s kt hn (Certificate of No Marriage Record) do Lc s
Ht (County Clerk) hoc c quan tng ng ca a phng cp c gi tr trong vng 06
thng. Giai on tm kim h s (search period) bt u t khi tui kt hn (n 18 tui;
nam 20) cho ti hin nay, hoc t khi ly hn hoc v/chng b cht cho ti nay.
4. Giy xc nhn ca bc s chuyn khoa tm thn (Certificate of Good Mental Health)
xc nhn qu v khng mc bnh tm thn, hoc mc bnh tm thn nhng cha n mc
khng c kh nng nhn thc c hnh vi ca mnh (mu giy khm sc khe song ng
nh km l nhm to iu kin cho qu v). Qu v lin h vi bc s ca mnh c gii
thiu ti bc s chuyn khoa tm thn.
5. L lch c nhn (Biographic Information Sheet) theo mu song ng nh km.
6. Bn sao h chiu (Passport) hoc th xanh (Permanent Resident Card) (c xc nhn sao
ng t bn chnh ca Cng chng vin) .
LU :
-

Trc khi gi n i s qun c hp php ha, cc giy t nu trn cn c:

+ xc nhn ca Cng chng vin - Notary Public i vi giy t nu ti mc 1, 2, 4, 5, 6 v
ca H tch vin (Registrar) hoc Lc s Ta (Court Clerk) i vi giy t nu ti mc 3;
+ xc nhn ca B Ngoi giao Tiu bang (State-level Department of State) hoc Vn phng
Cng chng (Office of Authentification) thuc B Ngoi giao Tiu bang i vi cc ch k
v thm quyn ca Cng chng vin (Notary Public),(Ch : nu cc vn bn do cng mt
Cng chng vin xc nhn th ch cn mt vn bn ca B Ngoi giao Tiu bang i vi
thm quyn ca Cng chng vin ) hoc H tch vin (Registrar) hoc Lc s Ta
(Court Clerk) nu trn. i s qun ch hp php ha nhng giy t c chng
thc bi B Ngoi giao Tiu bang.

Trng hp ly hn cn np thm bn sao Phn quyt ly hn ca Ta n c (1) chng thc

ca Lc s To hoc Cng chng vin v (2) xc nhn ca B Ngoi giao Tiu Bang i vi
ch k v thNm quyn ca Cng chng vin hoc Lc s To nu trn.

Trng hp c v/chng cht cn np thm bn sao Giy chng t c (1) xc nhn ca

H tch vin hoc Cng chng vin v (2) xc nhn ca B Ngoi giao Tiu bang i vi ch
k v thNm quyn ca H tch vin hoc Cng chng vin nu trn.

II. Giy y quyn np h s ng k kt hn:

Nu khng th v Vit Nam trc tip np n, qu v c th y quyn cho ngi Vit Nam
np. Ngi Vit nh c ti Hoa k c th gi Giy y quyn (theo mu nh km) cng
photocopy h chiu hoc th xanh ti i s qun xc nhn (sau khi k v ghi y h tn)
hoc hp php ha (sau khi c Cng chng vin k v B Ngoi giao Tiu bang xc nhn).
L ph:
Tr bng MONEY ORDER hoc CASHIERS CHECK (CERTIFIED CHECK) cho EMBASSY OF
VIETNAM.
Thi gian gii quyt:
H s thng:
H s gp:

10 -20 ngy lm vic k t khi nhn c h s.

3-5 ngy lm vic k t khi nhn c h s.

Gi tr:
Nu qu v c yu cu, i s qun c th gi tr kt qu qua ng bu in bng dch v c
tracking number USPS Express Mail. Qu v cn cung cp b th tr tin cc ph ca dch v
trn v ghi r a ch ngi nhn i s qun gi tr. V s an ton ca giy t ca qu v, xin
ngh qu v KHNG s dng cc dch v pht chuyn th khc.
Qu v cn ghi li tracking number ca b th gi i v gi tr thun li cho vic tra cu kt qu.
Nu qu v c cu hi hoc cn thm thng tin xin vui lng lin h:
Phng Lnh s ca i s qun:
Gi nhn/tr h s ti i s qun:
in thoi:
Fax:
Website:
a ch:

09h30 12h30 cc bui sng t Th Hai ti Th Su.

(202) 861 0737 ext 237 t 10h00 n 11h30 cc bui
sng t th Hai n th Su
(202) 861 1297 v (202) 861 0917
www.vietnamembassy.us
1233 20th Street, NW, Suite 400,
Washington, DC 20036

PHIU NGHN
(hp php ha lnh s hoc chng thc)
LETTER OF REQUEST
(for consular legalization/certification)
Knh gi : i s qun Vit Nam ti Oa- sing- tn D.C
Embassy of Vietnam in the U.S.A.
1. Ngi ngh /Applicant:
H v tn/ Full name :
H chiu s/ Passport or ID No :..ngy cp/ Date of isuance:
Ni cp/Place of isuance:
Hin tr ti/Address :.

in thoi/Telephone No:...
2. Cc loi vn bn ngh :
1/.
2/.
3/.
4/.
5/.

Tng cng/Total :..vn bn/document(s)

3. Mc ch s dng :
Yu cu chng thc/ hp php ha lnh s vn bn nu trn s dng ti ... (tn nc),
vo mc ch
Document(s) will be applicable in .(name of country) , for the purpose of
...
Ti xin cam oan nhng li khai trn l ng s tht v hon ton chu trch nhim trc php lut v
tnh xc thc ca vn bn km theo.
I hereby confirm that the information provided above is true and correct in all details. I am fully liable
for the authenticity of the above-mentioned documents.
Lm ti .ngythng..nm.
Done at.on date/month/year.
Ngi ngh (k tn)/Applicants signature

H v tn/Full name:
Lu / Notice :
nh km 01 bn photocopy h s v h chiu/ID lu ti i s qun
Please attach a copy of your ID/pasport and document(s) for Embassys record;

CNG HA X HI CH NGHA VIT NAM

Socialist Republic of Vietnam

c lp T do Hnh phc
Independence Liberty Happiness
nh/Photo
Nam/Male
2x2
Cha qu 6 thng
Taken within last
6 months

nh/Photo
N/Female
2x2
Cha qu 6 thng
Taken within last
6 months

T KHAI NG K KT HN
Application for Marriage Registration

Knh gi: U ban Nhn dn Tnh/Thnh ph . . . . . . . . . . . . .

To:

The Provincial Peoples Committee of

Ngi khai

Nam

Applicant

Male

Female

H v tn:
Full Name:

Ngy sinh:
Date of Birth

Ni sinh:
Place of Birth

Dn tc:
Ethnic Group

Quc tch:
Nationality

Ngh nghip:
Occupation

Qu qun1:
Place of Origin

Ni c tr2:
Current Address

Loi giy t/Type of Doc.3

CMND
ID Card

S/Number
Ngy cp/Date of Issue
Ni cp/Place of Issue
Kt hn ln th:

H chiu
Th xanh
Passport

Green Card

CMND
ID Card

H chiu
Th xanh
Passport

Green Card

Married for the

________time

________ time

Chng ti cam oan nhng li khai trn y l ng s tht, vic kt hn ca chng ti l t nguyn,
khng vi phm lut hn nhn v gia nh Vit Nam, v xin chu trch nhim trc lut php v li khai ca
mnh.
We solemnly declare that the above statements are true and complete, that our application for marriage is of our own free
will and not in violation of the Vietnam Family and Marriage Code, and that we take full responsibility before the law for our
statements.

ngh U ban xem xt, ng k.

We respectfully submit the application to the Peoples Committee for consideration and registration.

Lm ti . . . . . . . . . , ngy . . . thng . . . nm . . . .
Place

on

dd

mm

yy

Ngi nam k tn

Ngi n k tn

Signature

Signature

H v tn: . . . . . . . . . . .

H v tn: . . . . .

Full Name in Print

Full Name in Print

For the Notary Public Phn dnh cho Cng chng vin
Sworn to and subscribed before me on this . . . day of . . . . . . . . . . . . . . . . . . . . . . . . .
Tuyn th v k tn trc mt ti ngy

Ghi theo ni sinh trng ca cha . Nu khng r cha l ai, th theo ni sinh trng ca m . Nu
khng xc nh c cha, m , th theo ni sinh trng ca ngi nui dng t nh. Indicate fathers birth
place. If father is unkown, indicate mothers birth place. If both parents are unknown, indicate childhood guardians birth place.
2

Ghi ng theo ni thng tr. Trong trng hp khng c ni thng tr, th ghi theo ni tm tr v ghi r
Tm tr. Indicate the exact permanent address. If there is no permanent address, indicate temporary address and state clearly
temporary address.

Ghi r loi giy t. Indicate clearly the type of the document.

AFFIDAVIT OF SINGLE STATUS

TUYN TH C THN

On this date of

. . . . . . . . . . . . . .

Full Name:

, I, the undersigned,
, ti, k tn di y,

Vo ngy

. . . . . . . . . . . . . . . . . . . . . . . . . . .

H v tn:

Date of Birth:

. . . . . . . . . . . . .

Place of Birth:

Ngy sinh:

dd

Ni sinh:

mm

yyyy

Social Security Number: . . . . .

. . . . .

S th an sinh x hi:

Current Occupation:

.Nam:

N:

Male

Female

. . . . . . . . . . . . . . . . .

US Passport (or Green Card) No: . . . . . . . . . . .

S h chiu / th xanh

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ngh nghip hin nay

Employer (Name, Add, Tel):

. . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . .

Ni lm vic (Tn, a ch, in thoi)

. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . ( . ) . . .

Permanent Address (Str. Add, City, State, Tel): . . . . . . . . . . . . . . . . . . . . . . . . . . .

a ch thng tr:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.

. . . . . . . . ( . ) . . . . .

being duly sworn in, hereby solemnly declare that, under the law of the United States, I am currently single, have
never been married (or was divorced/widowed on . . . . . . . . . . . . . . . . . . . . . . . and
have never been remarried since that date) and fully qualified to marry the following Vietnamese citizen:
xin tuyn th, theo lut php Hoa k, ti hin c thn, cha tng kt hn bao gi (hoc li hn/ga t .
cha ti gi t ti nay), v hi iu kin kt hn vi cng dn Vit Nam c tn di y:

Full Name:

. . . . . . . . . . . . . . . . . . . . . . . . . . .

H v tn:

Date of Birth:

. . . . . . . . . . . . .

Place of Birth:

Ngy sinh:

dd

Ni sinh:

ID Card Number: . . . .

mm

yyyy

. . . . . . v

Nam:

N:

Male

Female

. . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

S CMND:

Permanent Address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
a ch thng tr:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . .

I declare that the statements made in this affidavit are true and correct and I take full responsibility for them under the
US law of perjury. I also declare that I shall marry the above-named person according to the law of Vietnam.
Ti xin cam oan nhng li tuyn th trn l ng s tht v xin chu trch nhim v nhng li tuyn th trc lut php Hoa K. Ti
xin cam oan s kt hn vi cng dn Vit Nam c tn trn theo lut php Vit Nam.

Signature of the Affiant:

Full Name in Print:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ngi tuyn th k v ghi y h tn:

For the Notary Public Phn dnh cho Cng chng vin
Sworn to and subscribed before me on this . . . day of . . . . . . . . . . . . . . . . . . . . . . . . .
Tuyn th v k tn trc mt ti ngy

PRE-MARITAL EXAMINATION OF MENTAL HEALTH

Kt qu Khm Sc khe Tm thn Tin Hn nhn
Part/Phn I: Doctors Information/Bc s
Full Name:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

H v tn:

License Number:

. . . . . . . . . . . . . . . . . . . . . . . . . . .

Giy php hnh ngh s:

Name of Institution:

. . . . . . . . . . . . . . . . . . . . . . . . . . .

Tn Phng khm/Bnh vin

Address and Tel:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

a ch v s phone

Part/Phn II: Applicants Information/ng n

Full Name:

Mr.
Ms. . . . . . . . . . . . . . . . . . . . . . . . .

H v tn:

ng

Date of Birth: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Ngy sinh:

dd

mm

yyyy

Address and Tel:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

a ch:

Part/Phn III: Results/Kt lun:

Currently,
Hin ti,

Mr.
Ms. . . . . . . . . . . . . . . . . . . . . . . . .
ng
C

Does NOT suffer from mental illnesses.

Khng mc bnh tm thn.

Has mental problems, but NOT to the extent of losing consciousness of his/her actions;
Mc bnh tm thn, nhng cha n mc khng c kh nng nhn thc c hnh vi ca mnh;

Has a mental illness and is not capable of being conscious of his/her actions.
Mc bnh tm thn, khng c kh nng nhn thc c hnh vi ca mnh.
Part/Phn IV: Attachments/nh km

Mental Assessment

Others/Khc

. . . . . . . . . .

Date of Examination: . . . . . . . . . . . .
Ngy khm:

Signature of Doctor: . . . . . . . . . . . .
Bc s k tn:

Full Name in Print: . . . . . . . . . . . . .

Ghi y h tn:

For the Notary Public Phn dnh cho Cng chng vin

CNG HA X HI CH NGHA VIT NAM

C LP T DO HNH PHC
-----------------------------------------------------

N XIN VNG MT KHI NP H S KT HN V GIY Y QUYN

(POWER OF ATTORNEY)

Knh gi:

S T php. . . . . . . . . . . . . . .
The Deparment of Justice of

Ti, k tn di y, : . . . . . .

. . . . . .

. . .

. . . . . . . . . . . . . .

I, the undersigned,

Sinh ngy

:. . . . . .

Date of birth

dd

Mang h chiu s

:. . . . . .

. . . . . .

. . .

. . . . . . . . . . . . . .

:. . . . . .

. . . . . .

. . .

. . . . . . . . . . . . . .

:. . . . . .

. . . . . .

. . .

. . . . . . . . . . . . . .

mm

. . . Ti : . . . .
yyyy

. . .

. . . . . . . . . . .

Place of birth

Passport number

Thng tr
Permanent address

v l do
for reasons of

lm n ny xin c php vng mt khi np h s xin kt hn v y quyn cho:

hereby request permission to be absent in submitting my application for marriage registration and entrust:

H v tn

:. . . . . .

. . . . . .

. . .

. . . . . . . . . . . . . .

Full name

Sinh ngy

:. . . . . .

Date of birth

dd

S CMND

:. . . . . .

mm

. . . Ti : . . . .
. .

Ni cp : . . . .

ID Card No.

Thng tr

. . .

. . . . . . . . . . .

Place of birth

yyyy

. . .

. . . . . . . . .

Issuing authority

:. . . . . .

. . . . . .

. . .

. . . . . . . . . . . . . . .

Permanent address

thay ti lm cc th tc ng k kt hn v np h s ng k kt hn
to act on my behalf in completing all the procedures concerning marriage registration and
in submitting the application package for a marriage certificate

ti S T php. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
at the Justice Department of

Lm ti . .

. .

. . .

Ngy . . . thng . . nm . .

Place

dd

mm

yyyy

Ngi y quyn k tn
Signature

H v tn:. . . . . . . . . . . .
Full name

For the Notary Public Phn dnh cho Cng chng vin
Sworn to and subscribed before me on this . . . day of . . . . . . . . . . . . . . . . . . . . . . . . .
Tuyn th v k tn trc mt ti ngy

CNG HA X HI CH NGHA VIT NAM

Socialist Republic of Vietnam
c lp T do Hnh phc
Independence Liberty Happiness

nh/Photo
2x2
Cha qu 6 thng
Taken within last
6 months

H v tn:
. .


Full Name:
Ngysinh:
. .
Date of Birth:
Ni sinh:
. .
Place of Birth:
Dn tc:
. .
Ethnic Group
Ngh nghip: . .
Occupation:
Ni lm vic: . .
Employer:
. .
Qu qun4:
Place of origin:
Ni c tr5: . .
Current Address:


H chiu
No. of Passport
Ni cp
:
Place of Issue:

L LNCH C NHN
BIOGRAPHIC INFORMATION SHEET

. . . . . . . . . . . . . . . . . . . . . . . . . .

Nam:

N:

Family
First
Middle
Male
Female
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
dd
mm
yyyy
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . .
Quc tch:
. . . . . . . . . . . . . .
Nationality:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Th xanh: S . . . . . . . . . . . . . . . . . . . . . . .
Green Card
. . . . . . . . . . . . .
Ngy cp:
. . . . . . . . . . .
Date of Issue:
HON CNH C NHN/PERSONAL INFORMATION

1. lm g, u t 15 tui n nay? What have you done and where have you lived since the age of
15?
T - n/Dates
Cng vic/Employment
a ch/Address

2. Tnh trng hn nhn cho n nay (nu c, ghi r h tn, ni c tr ca ngi kt hn trc y, l
do chm dt hn nhn): History of Marital Status (if have been married, indicate full name and address
of previous spouse(s) and reasons for termination)
T nm - n nm
H tn
a ch
L do chm dt

Dates

Full Name

Address

Reasons for Termination

HON CNH GIA NH/FAMILY INFORMATION

1. Cha, m6/Parents:
H v tn
Full Name

Ngy sinh Dn tc Quc tch

Date of Birth Ethnicity Nationalit
y

Qu qun
Place of
Origin

Ni c tr
Current Address

Cha
Father
M
Mother
2. Anh, ch, em rut/Full Siblings:
Anh ch em
H v tn
Ngy sinh
Siblings
Full Name
Date of
Birth

Ni c tr
Current Address

Ti cam oan nhng li khai trn y l ng s tht v xin chu trch nhim trc php lut v li khai
ca mnh. I undertake that the above statements are true and complete and that I take full responsibility
before the law for them.
Lm ti . . . . . . . . . , ngy . . . thng . . . nm .
Place on
dd
mm
yyyy
Ngi khai k tn
Signature

H v tn: . . . . . . . . . .
Full Name in Print
For the Notary Public Phn dnh cho Cng chng vin
Sworn to and subscribed before me on this . . . day of . . . . . . . . . . . . . . . . . . . . . . . . .
Tuyn th v k tn trc mt ti ngy

Ghi theo ni sinh trng ca cha . Nu khng r cha l ai, th theo ni sinh trng ca m . Nu khng xc nh c
cha, m , th theo ni sinh trng ca ngi nui dng t nh. Indicate fathers birth place. If father is unkown, indicate
mothers birth place. If both parents are unknown, indicate childhood guardians birth place.
5
Ghi ng theo ni thng tr. Trong trng hp khng c ni thng tr, th ghi theo ni tm tr v ghi r Tm tr.
Indicate the exact permanent address. If there is no permanent address, indicate temporary address and state clearly
temporary address.
6
Nu l cha, m nui th phi ghi r. If parents are adoptive, so state clearly.