Form Dch-0838 - Record Of Divorce Or Annulment
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1RECORD OF
________________________
DIVORCE OR ANNULMENT
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Court Case Number
MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
__________________________________
_________________________________
By authority of MCL 333.2813.
State File Number
County
1. Plaintiff’s Full Name _______________________________________________________ 2. Plaintiff’s Birthdate ______________
□
□
Male
Female
(First, Middle, Last)
(Month, Day, Year)
3. Last Name Before First Married (if different) _____________________________________________________________________
4. Plaintiff’s Residence _______________________________________________________________________________________
(City, Village, or Township)
(County)
(State)
5. Plaintiff’s Birthplace ______________________________________________________ 6. Number of this Marriage __________
(State or Foreign Country)
(First, Second, etc. - Specify)
7. Defendant’s Full Name ____________________________________________________ 8. Defendant’s Birthdate ____________
□
□
Male
Female
(First, Middle, Last)
(Month, Day, Year)
9. Last Name Before First Married (if different) _____________________________________________________________________
10. Defendant’s Residence _____________________________________________________________________________________
(City, Village, or Township)
(County)
(State)
11. Defendant’s Birthplace ___________________________________________________ 12. Number of this Marriage __________
(State or Foreign Country)
(First, Second, etc. - Specify)
13. Place of this Marriage ______________________________________________________________________________________
□
(City, Village, or Township)
(County)
(State or Foreign Country)
15. Date Couple Last Resided
Check if
in Same Household
Not
14. Date of this Marriage _____________________
Separated
_____________________
(Month, Day, Year)
(Month, Day, Year)
□
Check If
16. Number of Minor Children in Household at Separation Date (Filing Date if Not Separated)
______________
None
(Number)
17. Plaintiff’s Attorney _________________________________________________________________________________________
(Name - Type or Print)
(Bar Number)
18. Attorney’s Address _________________________________________________________________________________________
(Number and Street)
(City)
(State)
(Zip Code)
20. Number of Minor Children Whose
19. Judgement of ____________________
Physical Custody was Awarded to: Plaintiff____ Defendant____ Joint____ Other____
(Divorce/Annulment - Specify)
(Number)
(Number)
(Number)
(Number)
□
□
No Children
Unknown
21. Judgement Recorded on _______________________ 22. I certify that this Divorce was granted on ________________________
(Month, Day, Year)
(Month, Day, Year)
23. Certifying Official _________________________________________________________________________________________
(Signature)
(Title)
(Date Signed)
Failure to provide the required information is a misdemeanor punishable by imprisonment
of not more than 1 year or a fine of not more than $1,000.00 or both.
DCH-0838 (Rev. 07/2015)
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Parent category: Legal