Form Hhs-73 - Certificate Of Dissolution Of Marriage Or Annulment Worksheet
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11. County/Tribal Court
State of Nebraska
Department of Health and Human Services Finance and Support
Vital Records
2. Court Record Number
2. Court Record Number
2. Court Record Number
2. Court Record Number
Certificate of Dissolution of Marriage or Annulment
Certificate of Dissolution of Marriage or Annulment
WORKSHEET ONLY
3. Husband’s Name (First, Middle, Last, Suffix)
4a. Current Residence - Country
4a. Current Residence - Country
4a. Current Residence - Country
4b. State
4b. State
4b. State
4c. County
4c. County
4c. County
4d. City, Town or Location
4d. City, Town or Location
4d. City, Town or Location
4e. Residence - Street and Number
4e. Residence - Street and Number
4e. Residence - Street and Number
4f. Zip Code
4f. Zip Code
4f. Zip Code
5. Place of Birth (City and State or Foreign Country)
5. Place of Birth (City and State or Foreign Country)
5. Place of Birth (City and State or Foreign Country)
6. Date of Birth (Mo., Day, Yr.)
6. Date of Birth (Mo., Day, Yr.)
6. Date of Birth (Mo., Day, Yr.)
7a. Wife’s Name (First, Middle, Last, Suffix)
7a. Wife’s Name (First, Middle, Last, Suffix)
7a. Wife’s Name (First, Middle, Last, Suffix)
7a. Wife’s Name (First, Middle, Last, Suffix)
7b. Maiden Name
7b. Maiden Name
7b. Maiden Name
7b. Maiden Name
8a. Current Residence - Country
8a. Current Residence - Country
8a. Current Residence - Country
8a. Current Residence - Country
8b. State
8b. State
8b. State
8b. State
8c. County
8c. County
8c. County
8c. County
8d. City, Town or Location
8d. City, Town or Location
8d. City, Town or Location
8d. City, Town or Location
8e. Residence - Street and Number
8e. Residence - Street and Number
8e. Residence - Street and Number
8e. Residence - Street and Number
8f. Zip Code
8f. Zip Code
8f. Zip Code
8f. Zip Code
9. Place of Birth (City and State or Foreign Country)
9. Place of Birth (City and State or Foreign Country)
9. Place of Birth (City and State or Foreign Country)
10. Date of Birth (Mo., Day, Yr.)
10. Date of Birth (Mo., Day, Yr.)
10. Date of Birth (Mo., Day, Yr.)
11a. Place of Marriage - State
11a. Place of Marriage - State
11a. Place of Marriage - State
11a. Place of Marriage - State
11a. Place of Marriage - State
11b. County
11b. County
11b. County
11b. County
11b. County
11c. City
11c. City
11c. City
11c. City
11c. City
11d. Date of Marriage
11d. Date of Marriage
11d. Date of Marriage
11d. Date of Marriage
11d. Date of Marriage
(Mo., Day, Yr.)
(Mo., Day, Yr.)
(Mo., Day, Yr.)
(Mo., Day, Yr.)
12a. Number of Children under 18 in this Household
12a. Number of Children under 18 in this Household
12b. Number of Children Under 18 Whose Physical Custody was Awarded to:
12b. Number of Children Under 18 Whose Physical Custody was Awarded to:
______Husband
______Husband
______Wife
______Wife
______Joint Husband/Wife
______Joint Husband/Wife
Number_______________________________
Number_______________________________
______Other_________________________________________
______Other_________________________________________
No Children Awarded Custody
13. Plaintiff
13. Plaintiff
14. List Former Name of Wife, if restored
14. List Former Name of Wife, if restored
Husband
Wife
15a. Attorney for Plaintiff - Name
15a. Attorney for Plaintiff - Name
15b. Address (Street, City or Town, State and Zip Code)
15b. Address (Street, City or Town, State and Zip Code)
16a. I certify that the marriage of the above name persons was dissolved on
16a. I certify that the marriage of the above name persons was dissolved on
16b. Type of Decree
16b. Type of Decree
(Mo., Day, Yr.)
(Mo., Day, Yr.)
______Dissolution
______Dissolution
______Annulment
______Annulment
17. Clerk of the District Court or Tribal Court Making Return to the Department of Health and Human Services Finance and Support
Information For Administrative Use Only. Information below will not appear on certified copies of the record
18. Settlement(s) Made
Alimony Yes No
Child Support Yes No
Property Settlement Yes No
Medical Reimbursement Yes No
19. Social Security Numbers
Husband:___________________________________ Wife:___________________________________
20a. Is Husband of Hispanic or Latino Origin? Yes No
20b. Is Wife of Hispanic or Latina Origin? Yes No
20b. Is Wife of Hispanic or Latina Origin?
21a. Husband
Race
21b. Wife
Check the race(s) each person considers him/herself to be
White/Caucasian
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacifi c Islander
HHS-73 (55073) 6/06
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