Statistical Record Of Divorce
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1
2STATE OF MISSISSIPPI
STATISTICAL RECORD OF DIVORCE
Type or Print with Black Ink
Court File Number
State File
Number
Husband
1. Name (first, Middle, Last)
Last Name prior to 1
s t
2.
3. Residence-State
or
marriage
Gender
Partner
4. Race (check one or more races to indicate what
the applicant considers himself/herself to be)
White
Black/African American
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Native Hawaiian
Guamanian or
Chamorro
Samoan
American Indian or
Alaska Native (Name of the enrolled or principal
tribe)
,
Other
Pacific Islander (Specify)
,
Other Asian (Specify)
,
Other (Specify)
Wife
5. Name (first, Middle, Last)
Last Name prior to 1
s t
6.
7. Residence-State
or
marriage
Gender
Partner
8. Race (check one or more races to indicate what
the applicant considers himself/herself to be)
White
Black/African American
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Native Hawaiian
Guamanian or
Chamorro
Samoan
American Indian or
Alaska Native (Name of the enrolled or principal
tribe)
,
Other
Pacific Islander (Specify)
,
Other Asian (Specify)
,
Other (Specify)
Marriage
9. Place of Marriage (State or Foreign Country)
10. Date of Marriage
11. Date couple last resided
and
in same household
Decree
(mo/day/year)
12. Number of children under 18 in household as
13.Legal Grounds for Decree
of the date in Item 9
(Briefly Stated)
14. Suit Contested?
15. Petitioner:
15. Petitioner:
Yes
No
Wife/Partner
Husband/Partner
Joint
Other (Specify)
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