“STATE OF ARKANSAS COUNTY OF BE IT KNOWN THAT on this. . . . . . . . . . day of . . . . . . . . . . . . . ., . . . . . ., before me the undersigned notary, personally came and appeared: . . . . . . . . . . . . . . and . . . . . . . . . . . . .

who after being duly sworn by me, a notary, deposed and stated that: Affiants acknowledge that they have received premarital counseling from a priest, minister, rabbi, clerk of the Religious Society of Friends, any clergyman of any religious sect, or a professional marriage counselor, which marriage counseling included: A discussion of the seriousness of covenant marriage; Communication of the fact that a covenant marriage is a commitment for life; The obligation of a covenant marriage to take reasonable efforts to preserve the marriage if marital difficulties arise; and That affiants both read the pamphlet entitled “Covenant Marriage Act” developed and promulgated by the Administrative Office of the Courts, which provides a full explanation of a covenant marriage, including the obligation to seek marital counseling in times of marital difficulties and the exclusive grounds for legally terminating a covenant marriage by divorce or divorce after a judgment of separation from bed or board

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(Name of prospective spouse) . . . . . . . . . . . . .

(Name of prospective spouse) . . . . . . . . . . . . .

SUBSCRIBED AND SWORN TO BEFORE ME THIS DAY OF . . . . . . . . . . . . . ., . . . . .

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NOTARY PUBLIC ATTESTATION The undersigned attests that the affiants did receive counseling from me as to the nature and purpose of marriage, which included a discussion of the seriousness of covenant marriage, communication of the fact that a covenant marriage is for life, and the obligation of a covenant marriage to take reasonable efforts to preserve the marriage if marital difficulties arise

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Counselor”