Worksheet For Divorce Or Annulment Registration - Kdhe

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KANSAS DEPARTMENT OF HEALTH AND ENVIRONMENT
Office of Vital Statistics
WORKSHEET FOR DIVORCE OR ANNULMENT REGISTRATION
This worksheet is to be completed by the prevailing party or the legal representative of the prevailing party and returned to the district court before the divorce
or annulment can be filed. This information will be used by the clerk of the court to complete the official divorce or annulment certificate (report).
This worksheet is not to be forwarded to the Office of Vital Statistics.
1. HUSBAND’S NAME (First, Middle, Last)
2. DATE OF BIRTH (Month, Day, Year)
3. RESIDENCE-STATE
4. COUNTY
5. WIFE’S NAME (First, Middle, Last)
6. WIFE’S LAST NAME PRIOR TO FIRST MARRIAGE
7. DATE OF BIRTH (Month, Day, Year)
8. RESIDENCE-STATE
9. COUNTY
10. PLACE OF THIS MARRIAGE - STATE
11. COUNTY
12. DATE OF THIS MARRIAGE
13. NUMBER OF CHILDREN UNDER 18 IN THIS
OR FOREIGN COUNTRY
(Month, Day, Year)
HOUSEHOLD AS OF DATE IN ITEM 17
14. PETITIONER
15. NAME OF PETITIONER’S ATTORNEY (Type)
Husband
Wife
Both
Other (Specify)
16. ATTORNEY’S ADDRESS (Street and Number or Rural Route, City or Town, State, Zip Code)
18. TYPE OF DECREE-(Specify)
19. COUNTY OF DECREE
20. CASE NUMBER
17. DATE DECREE FILED
(Month, Day, Year)
Divorce
Annulment
THE INFORMATION BELOW WILL NOT APPEAR ON CERTIFIED COPIES OF THE RECORD.
K.S.A. 65-2422B, REQUIRES THE DIVORCE REPORT TO INCLUDE THE SOCIAL SECURITY NUMBER OF BOTH PARTIES TO MAKE SUCH INFORMATION AVAILABLE TO THE SECRETARY OF
SOCIAL AND REHABILITATION SERVICES FOR THE PURPOSE OF ESTABLISHING, MODIFYING, OR ENFORCING A SUPPORT OBLIGATION.
21. HUSBAND’S SOCIAL SECURITY NUMBER
22. WIFE’S SOCIAL SECURITY NUMBER
23. NUMBER OF THIS MARRIAGE First,
24. IF PREVIOUSLY MARRIED, LAST MARRIAGE ENDED
Second, etc. (Specify below)
By Death, Divorce, or Annulment (Specify below)
Date (Month, Day, Year)
23a. HUSBAND
24a. HUSBAND
24b HUSBAND
23b. WIFE
24c. WIFE
24d. WIFE
25. HISPANIC ORIGIN (Check the box or boxes that best
26. RACE (Check one or more boxes to indicate what race(s) you consider yourself to be.)
describes whether you are Spanish, Hispanic, or Latino.
26a. HUSBAND
26b. WIFE
Check the “no” box if you are not Spanish, Hispanic, or
Latino.)
White
Korean
White
Korean
25a. HUSBAND
25b. WIFE
Black or
Vietnamese
Black or
Vietnamese
African American
African American
No, not Spanish/
No, not Spanish/
Hispanic/Latino
Hispanic/Latina
American Indian or
Other Asian (Specify)
American Indian or
Other Asian (Specify)
Alaska Native
Alaska Native
Yes, Mexican/Mexican
Yes, Mexican/Mexican
American/Chicano
American/Chicana
(Name of the enrolled
(Name of the enrolled
or principal tribes)
or principal tribes)
Yes, Puerto Rican
Yes, Puerto Rican
Yes, Cuban
Yes, Cuban
Yes, Central American
Yes, Central American
Native Hawaiian
Native Hawaiian
Yes, South American
Yes, South American
Asian Indian
Guamanian or Chamorro
Asian Indian
Guamanian or Chamorro
Yes, other Spanish/
Yes, other Spanish/
Chinese
Samoan
Chinese
Samoan
Hispanic/Latino (Specify)
Hispanic/Latina (Specify)
Filipino
Other Pacific Islander
Filipino
Other Pacific Islander
(Specify)
(Specify)
Japanese
Japanese
Unknown
Unknown
Other (Specify)
Other (Specify)
Unknown
Unknown
27. EDUCATION (Check the box that best describes the highest degree or level of school completed.)
th
th
th
27a. HUSBAND’S EDUCATION
8
grade or less
9
- 12
grade; no diploma
High school graduate or GED
Some College credit, but no degree
Associate degree (e.g., AA,AS)
Bachelor’s degree (e.g., BA, AB, BS)
Unknown
Master’s degree (e.g., MA, MS, MEng, MEd, MSW, MBA)
Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DDS, DVM, LLB, JD)
th
th
th
27b. WIFE’S EDUCATION
8
grade or less
9
- 12
grade; no diploma
High school graduate or GED
Some College credit, but no degree
Associate degree (e.g., AA,AS)
Bachelor’s degree (e.g., BA, AB, BS)
Unknown
Master’s degree (e.g., MA, MS, MEng, MEd, MSW, MBA)
Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DDS, DVM, LLB, JD)
VS243 Rev.04/07/04

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