Form Vs-165 - Information On Suit Affecting The Family Relationship - Texas Department Of State Health Services Page 2

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3 (

)

DDITIONAL CHILDREN AFFECTED BY THIS SUIT FROM SECTION

IF APPLICABLE

23a.

(

)

CHILD CURRENT NAME

FIRST MIDDLE LAST SUFFIX

23b.

(mm/dd/yyyy)

23c.

23d.

(

)

DATE OF BIRTH

SEX

BIRTHPLACE

CITY

COUNTY AND STATE

23e.

) –

PRIOR NAME OF CHILD

IRST MIDDLE LAST SUFFIX

IF APPLICABLE

24a.

)

CHILD CURRENT NAME

IRST MIDDLE LAST SUFFIX

24b.

(mm/dd/yyyy)

24c.

24d.

(

)

DATE OF BIRTH

SEX

BIRTHPLACE

CITY

COUNTY AND STATE

24e.

) –

PRIOR NAME OF CHILD

IRST MIDDLE LAST SUFFIX

IF APPLICABLE

25a.

)

CHILD CURRENT NAME

IRST MIDDLE LAST SUFFIX

25b.

(mm/dd/yyyy)

25c.

25d.

(

)

DATE OF BIRTH

SEX

BIRTHPLACE

CITY

COUNTY AND STATE

25e.

) –

PRIOR NAME OF CHILD

IRST MIDDLE LAST SUFFIX

IF APPLICABLE

Instructions for Completing the Suit Affecting Parent Child Relationship Form

GENERAL REQUIREMENT:

All divorces/annulments (with or without children) and all suits affecting the parent-child relationship must be reported through the clerk of the

court to the State Vital Statistics Unit (VSU).

Consolidated reporting by petitioners, attorneys, and the courts is designed to make mandatory reporting more efficient, timely, and improve

the quality of reporting. However, this reporting system is only as good or timely as you make it; therefore, your attention in completing and

filing this report is critical.

Legal basis for this reporting is contained in Health and Safety Code §194.002 and Texas Family Code §§108.001-.002 and 108.004.

For information concerning reporting or questions about this form, contact field services at

fieldservices@dshs.texas.gov

or by phone at 512-

776-3010.

The VSU-165 form must be printed double-sided (one sheet not two).

For information on the court of continuing jurisdiction of a child, contact VSU at (888) 963-7111 ext. 2529. Inquiries should be addressed to

VSU, 1100 West 49th Street, Austin, Texas, 78756-3191; inquiries may also be faxed to (512) 776-7164 .

SECTION 1 GENERAL INFORMATION (REQUIRED)

This section must be completed for each report filed.



1a – d. Enter the required information to identify the court proceeding.



2. Check the type of suit being reported. This determines also which sections of the form must be completed. If more than one type of

order applies, check all that apply. Transfers from one jurisdiction to another must be reported in this section (if court number is unknown,

specify “unknown”).



3a – c. Complete the attorney information to assist in questions or follow up. If case was pro se, please enter the information of the

person completing this form.

SECTION 2 (IF APPLICABLE)

REPORT OF DIVORCE OR ANNULMENT OF MARRIAGE

All divorces/annulments must be reported, even if there were no minor children. All information is required.



4-9. Report the Petitioner’s information including maiden name (if applicable ).



10-15. Report the Respondent’s information, including maiden name (if applicable ).



16. Report the number of minor children affected by this divorce; if none, record “0.” This number must correspond to the listing of

children in Section 3.



17-18. Enter the date and place of the marriage being dissolved.

SECTION 3 (IF APPLICABLE)

CHILDREN AFFECTED BY THIS SUIT

Every child affected by the suit being reported must be listed, and all items concerning that child must be completed. If more than three children are

affected, check the “additional children listed on back of form” box, and continue to list the additional children. If more than 6 children complete

section 3 on another form, label it “continuation” and attached the continuation form to the original form.

VS-165 REV 07/2017

Texas Department of State Health Services - Vital Statistics