Certificate Of Divorce Or Annulment - State Of Kansas
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1STATE OF KANSAS
-------------------------------------------
DEPARTMENT OF HEALTH AND ENVIRONMENT
Office of Vital Statistics
CERTIFICATE OF DIVORCE OR ANNULMENT
T
COURT FILE NUMBER
STATE FILE NUMBER
1. HUSBAND’S NAME
FIRST
MIDDLE
LAST
HUSBAND
2. RESIDENCE – CITY, TOWN, OR LOCATION
3. COUNTY
4. STATE
5. BIRTHPLACE (State or Foreign Country)
6. DATE OF BIRTH (Month, Day, Year))
7. WIFE’S NAME
FIRST
MIDDLE
LAST
8. MAIDEN SURNAME
WIFE
9. RESIDENCE – CITY, TOWN, OR LOCATION
10. COUNTY
11. STATE
12. BIRTHPLACE (State or Foreign Country)
12. DATE OF BIRTH (Month, Day, Year)
14. PLACE OF THIS MARRIAGE – CITY, TOWN, OR LOCATION
15. COUNTY
16. STATE OR FOREIGN COUNTRY
17. DATE OF THIS MARRIAGE
MARRIAGE
(Month, Day, Year)
18. DATE COUPLE LAST RESIDED IN SAME HOME
19. NUMBER OF CHILDREN UNDER 18 IN THIS HOUSEHOLD
20. PETITIONER
(Month, Day, Year)
AS OF THE DATE IN ITEM 18
21. NAME OF PETITIONER’S ATTORNEY (Type)
22. Address (Street and Number or Rural Route Number, City or Town, State, Zip Code)
ATTORNEY
23. I CERTIFY THAT THE MARRIAGE OF THE ABOVE-NAMED
24. TYPE OF DECREE Divorce or Annulment (Specify)
25. DATE RECORDED (Month, Day, Year)
PERSONS WAS DISSOLVED ON: (Month, Day, Year)
26. NUMBER OF CHILDREN UNDER 18 WHOSE PHYSICAL CUSTODY WAS AWARDED
27. COUNTY OF DECREE
28. TITLE OF COURT
TO:
Husband _____ Wife ____ Joint (Husband/Wife) ___ Other _____
DECREE
No Children
29. SIGNATURE OF CERTIFYING OFFICIAL
30. TITLE OF CERTIFYING OFFICIAL
31. DATE SIGNED
(Month, Day Year)
THE INFORMATION BELOW WILL N OT APPEAR ON CERTIFIED COPIES OF THE RECORD
K.S.A. 65-2442b. REQUIRES THE DIVORCE REPORT TO INCLUDE THE SOCIAL SECURITY NUMBER OF BOTH PARTIES TO MAKE SURE SUCH INFORMATION AVAILABLE TO THE
SECRETARY OF SOCIAL AND REHABILITATION SERVICES FOR THE PURPOSE OF ESTABLISHING, MODIFYING OR ENFORCING A SUPPORT OBLIGATION.
HUSBAND
WIFE
SOCIAL SECURITY NUMBERS
STATISTICAL INFORMATION
32. NUMBER OF THIS
35. EDUCATION
MARRIAGE – First, Second, Etc.
33. PREVIOUSLY MARRIED, LAST MARRIAGE ENDED
34. RACE – Native American, Black, White,
(Specify only highest grade completed)
(Specify Below)
By Death, Divorce, or Annulment
Date (Month, Day, Year)
Etc. (Specify Below)
Elementary/Seco
College
(Specify below)
ndary (0/12)
(1-4 or 5+)
32.a.
33.a.
33.b.
34.a.
35. a.
HUSBAND
32.b.
33.c.
33.d.
26.b.
35.b.
WIFE
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