Form Vs-165 - Information On Suit Affecting The Family Relationship - Texas Department Of State Health Services
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1
2INFORMATION ON SUIT AFFECTING THE FAMILY RELATIONSHIP
(EXCLUDING ADOPTIONS)
SECTION I GENERAL INFORMATION (REQUIRED)
S
F
N
TATE
ILE
UMBER
1a. COUNTY __________________________
1b. COURT NO. ________________________
1c. CAUSE NO. ________________________
1d. DATE OF ORDER (mm/dd/yyyy) _________
2. TYPE OF ORDER (CHECK ALL THAT APPLY):
⃞ DIVORCE/ANNULMENT WITH CHILDREN (Se
⃞ DIVORCE/ANNULMENT WITHOUT CHILDREN (Sec 1
. 1,2
3)
2)
C
AND
AND
⃞ ESTABLISHMENT OF COURT OF CONTINUING JURISDICTION (S
1
3)
EC
AND
(Court Order Establishing Paternity, Conservatorship, Child Support or Termination of Parental Rights)
⃞ CHANGE IN THE NAME OF THE CHILD (S
1
3)
EC
AND
(P
3)
ROVIDE PRIOR AND NEW NAME OF CHILD IN SECTION
⃞ TRANSFER OF COURT OR CONTINUING JURISDICTION (S
1,3
)
EC
AND INFORMATION BELOW
TRANSFER TO: COUNTY __________ COURT NO. ________ STATE COURT ID# ______________
3a
.
3b
.
(including area code)
NAME OF ATTORNEY FOR PETITIONER
TELEPHONE NUMBER
3c
.
(
.
,
,
,
)
CURRENT MAILING ADDRESS
STREET AND NUMBER OR P
O BOX
CITY
STATE
ZIP
2 (
)
SECTION
IF APPLICABLE
REPORT OF DIVORCE OR ANNULMENT OF MARRIAGE
4. N
(
)
5.
(
1
ST
)
AME
FIRST MIDDLE LAST SUFFIX
MAIDEN LAST NAME
NAME BEFORE
MARRIAGE
6.
(
)
7.
8.
(mm/dd/yyyy)
PLACE OF BIRTH
CITY AND STATE OR FOREIGN COUNTRY
RACE
DATE OF BIRTH
9.
&
USUAL RESIDENCE
STREET NAME
NUMBER
CITY
STATE
ZIP
10. N
(
)
11.
(
1
ST
)
AME
FIRST MIDDLE LAST SUFFIX
MAIDEN LAST NAME
NAME BEFORE
MARRIAGE
12.
(
)
13.
14.
(mm/dd/yyyy)
PLACE OF BIRTH
CITY AND STATE OR FOREIGN COUNTRY
RACE
DATE OF BIRTH
15.
(
,
,
)
USUAL RESIDENCE
STREET AND NUMBER CITY
STATE
ZIP
16.
17.
(mm/dd/yyyy)
18.
(
)
NUMBER OF MINOR CHILDREN
DATE OF MARRIAGE
PLACE OF MARRIAGE
CITY AND STATE OR FOREIGN COUNTRY
3 (
)
SECTION
IF APPLICABLE
CHILDREN AFFECTED BY THIS SUIT
19a.
(
)
CHILD CURRENT NAME
FIRST MIDDLE LAST SUFFIX
19b.
(mm/dd/yyyy)
19c.
19d.
(
,
)
DATE OF BIRTH
SEX
BIRTHPLACE
CITY
COUNTY AND STATE
19e.
(
) –
PRIOR NAME OF CHILD
FIRST MIDDLE LAST SUFFIX
IF APPLICABLE
20a.
(
)
CHILD CURRENT NAME
FIRST MIDDLE LAST SUFFIX
20b.
(mm/dd/yyyy)
20c.
20d.
(
,
)
DATE OF BIRTH
SEX
BIRTHPLACE
CITY
COUNTY AND STATE
20e.
(
) –
PRIOR NAME OF CHILD
FIRST MIDDLE LAST SUFFIX
IF APPLICABLE
21a.
(
)
CHILD CURRENT NAME
FIRST MIDDLE LAST SUFFIX
21b.
(mm/dd/yyyy)
21c.
21d.
(
,
)
DATE OF BIRTH
SEX
BIRTHPLACE
CITY
COUNTY AND STATE
21e.
(
) –
PRIOR NAME OF CHILD
FIRST MIDDLE LAST SUFFIX
IF APPLICABLE
ഽ
.
ADDITIONAL CHILDREN LISTED ON BACK OF THE FORM
.
_____________________________________
I CERTIFY THAT THE ABOVE ORDER WAS GRANTED ON THE DATE AND PLACE AS STATED
SIGNATURE OF THE CLERK OF THE COURT
WARNING: This is a governmental document. Texas Penal Code, Section 37.10, specifies penalties for making false
entries or providing false information in this document. VS-165 REV 07/2017
VS-165 REV 07/2017
Texas Department of State Health Services - Vital Statistics
1
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