Chevalier de Notre Dame

Sacred Society of Saint Pius X

84 Strathmore Court, Dr

Coram,  NY 11727

Most Reverent Marital Registrar:

A dispensation is requested for:

(Name of Catholic faithful)

Who resides at:


Who is a (member of the Catholic faithful; or other faith) Kindly indicate:

The reasons are:

I, the undersigned, attest that I have investigated the freedom of the above name parties and find no other impediment to this marriage. I have instructed both parties concerning marriage and reasons given for the dispensation are true and just. Respectfully in Christ,

Signature of Priest


Chevaliers de Notre Dame

This dispensation should be sent to: The Preceptory, 84 Strathmore Court Drive, Coram, NY 11727

Promise and Declaration

To be taken by Catholic Party:

I reaffirm my faith in Jesus Christ and, with God's help intend to continue living that faith in the Catholic Church. At the same time, I acknowledge the respect I owe to the conscience of my partner in marriage. Therefore, I promise to do all in my power to share the faith I have received with our Children by having them baptized and educated in the religion of their parents.


 For the priest who witnesses this promise:

1] Check here if the Catholic party chooses to make the above promise orally.

[ The required promise and declaration have been made by the Catholic in my presence. The non- Catholic has been informed of this requirement so that it is certain that he (she) is aware of the promise and declaration on the part of the Catholic. Both partners are sincere and we are happy to witness their marriage sacrament..

Priest's signature: