La. Stat. tit. 9 § 275.1
"DECLARATION OF INTENT
We do solemnly declare that marriage is a covenant between a man and a woman who agree to live together as husband and wife for so long as they both may live. We understand the nature, purpose, and responsibilities of marriage. We have read the Covenant Marriage Act, and we understand that a Covenant Marriage is for life. If we experience marital difficulties, we commit ourselves to take reasonable efforts to preserve our marriage, including marital counseling.
With full knowledge of what this commitment means, we do hereby declare that our marriage will be bound by Louisiana law on Covenant Marriage, and we renew our promise to love, honor, and care for one another as husband and wife for the rest of our lives."
STATE OF LOUISIANA
PARISH OF _________________
BE IT KNOWN THAT on this ____ day of ________, ________, before me the undersigned notary, personally came and appeared:
____________________________________
(Insert names of spouses)
who after being sworn by me, Notary, deposed and stated that:
Affiants acknowledge that they have received 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 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 the affiants both read the pamphlet entitled "The Covenant Marriage Act" developed and promulgated by the office of the attorney general, 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.
____________________________
(Name of Spouse)
____________________________
(Name of Spouse)
SWORN TO AND SUBSCRIBED BEFORE ME THIS _____ DAY OF ___________, _______.
__________________________
NOTARY PUBLIC
ATTESTATION
The undersigned does hereby attest 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.
________________________
Counselor
La. R.S. § 9:275.1