Form Ccfc65 - Certificate Of Dissolution Of Marriage
Download a blank fillable Form Ccfc65 - Certificate Of Dissolution Of Marriage in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Ccfc65 - Certificate Of Dissolution Of Marriage with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1TYPE/PRINT
IN
PERMANENT
MISSOURI DEPARTMENT OF HEALTH
BLACK INK.
CERTIFICATE OF DISSOLUTION OF MARRIAGE
FOR
INSTRUCTIONS
SEE HANDBOOK.
CASE NUMBER
STATE FILE NUMBER
1.
HUSBAND’S NAME (First, Middle, Last)
1a. SOCIAL SECURITY NO.
2a.
RESIDENCE – CITY, TOWN, OR LOCATION
2b. STATE
2c.
ZIP CODE
HUSBAND
2d.
COUNTY
3. DATE OF BIRTH (Month, Day, Year)
4.
BIRTHPLACE (State or Foreign Country)
VS 800
Rev. 6/97
MO 580-0716
5a.
WIFE’S NAME (First, Middle, Last)
5b. MAIDEN SURNAME
5c. SOCIAL SECURITY NO.
(6/97)
6a.
RESIDENCE – CITY, TOWN, OR LOCATION
6b. STATE
6c.
ZIP CODE
WIFE
6d.
COUNTY
7. DATE OF BIRTH (Month, Day, Year)
8.
BIRTHPLACE (State or Foreign Country)
9a.
PLACE OF THIS MARRIAGE – CITY, TOWN OR LOCATION 9b. COUNTY
9c. STATE OR FOREIGN COUNTRY
10.
DATE OF THIS MARRIAGE
(Month, Day, Year)
11.
DATE COUPLE LAST RESIDED IN SAME
12. NUMBER OF CHILDREN UNDER 18 IN THIS HOUSEHOLD AS OF
13. PETITIONER
MARRIAGE
HOUSEHOLD (Month, Day, Year)
THE DATE IN ITEM 11
□
□
□
0
Husband
1
Wife
2
Joint
□
□
Number _____________
None
3
Other (Specify) __________________________
14a. NAME OF PETITIONER’S ATTORNEY (Type or Print)
14b.
ADDRESS (Street and Number or Rural Route Number, City or Town, State, Zip code)
ATTORNEY
15.
16.
TYPE OF DECREE
17. DATE RECORDED (Month, Day, Year)
I CERTIFY THAT THE MARRIAGE OF THE ABOVE-NAMED
PERSONS WAS DISSOLVED ON:
□
□
□
(Month, Day, Year)
0
Dissolution
1
Legal Separation
2
Annulment
18.
NUMBER OF CHILDREN UNDER 18 WHOSE PHYSICAL CUSTODY WAS
19.
CHILD SUPPORT WAS AWARDED
20.
COUNTY OF DECREE
21.
TITLE OF COURT
AWARDED TO:
TO:
□
1
Husband
DECREE
St. Louis
21st Circuit
□
Husband ___________________
Wife __________
2
Wife
□
Joint (Husband/Wife) __________
Other ____________
4
Other
□
□
No children
3
No child support awarded
22.
SIGNATURE OF CERTIFYING OFFICIAL
23. TITLE OF CERTIFYING OFFICIAL
►
Circuit Clerk
24.
NUMBER OF THIS
25.
IF PREVIOUSLY MARRIED, LAST MARRIAGE ENDED
27.
EDUCATION
MARRIAGE –
26.
RACE – American Indian, Black, White, etc.
(Specify only highest grade completed)
First, Second, etc.
By:
Date: (Month, Year)
(Specify below)
Elementary/Secondary
College
(Specify below)
(0-12)
(1-4 or 5+)
□
24a.
25a.
25c.
26a. 1
White
27a.
□
□
2
Death
2
Black
HUSBAND
□
□
3
Divorce, dissolution,
3
American Indian
□
or annulment
4
Other (Specify) __________________
□
24b.
25b.
25d.
26b. 1
White
27b.
□
□
2
Death
2
Black
WIFE
□
□
3
Divorce, dissolution,
3
American Indian
□
or annulment
4
Other (Specify)__________________
CCFC65 Rev. 9/04
WHITE – Vital Statistics
YELLOW - File
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal