Udoh Ovrs Form 14 - Certificate Of Divorce, Dissolution Of Marriage, Or Annulment
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1STATE OF UTAH - DEPARTMENT OF HEALTH
CERTIFICATE OF DIVORCE, DISSOLUTION
OF MARRIAGE, OR ANNULMENT
1. HUSBAND'S NAME (First, Middle, Last)
2a. RESIDENCE - CITY, TOWN OR LOCATION
2b. COUNTY
2c. STATE
3. BIRTHPLACE (State or Foreign Country)
4. DATE OF BIRTH (Month, Day, Year)
HUSBAND
8. EDUCATION: (Specify only
5. NUMBER OF THIS
7. RACE: White, Black,
6. IF NOT FIRST MARRIAGE, LAST MARRIAGE ENDED:
highest grade completed)
MARRIAGE -
Amer. Indian, etc.
First, Second, etc.
(Specify below)
By Death, Divorce, Dissolution,
Date (Mo., Day, Yr.)
Elementary/Secondary
College
(Specify below)
or Annulment (Specify Below)
(0 - 12)
(13-16 or 17+)
9a. WIFE'S NAME (First, Middle, Last)
9b. MAIDEN LAST NAME
10a. RESIDENCE - CITY, TOWN OR LOCATION
10b. COUNTY
10c. STATE
11. BIRTHPLACE (State or Foreign Country)
12. DATE OF BIRTH (Month, Day, Year)
WIFE
16. EDUCATION: (Specify only
13. NUMBER OF THIS
15. RACE: White, Black,
14. IF NOT FIRST MARRIAGE, LAST MARRIAGE ENDED:
highest grade completed)
MARRIAGE -
Amer. Indian, etc.
First, Second, etc.
(Specify below)
By Death, Divorce, Dissolution,
Date (Mo., Day, Yr.)
Elementary/Secondary
College
(Specify below)
or Annulment (Specify Below)
(0 - 12)
(13-16 or 17+)
`
17a. PLACE OF THIS MARRIAGE - CITY,
17b. COUNTY
17c. STATE OR FOREIGN COUNTRY 18. DATE OF THIS MARRIAGE
TOWN, OR LOCATION
(Month, Day, Year)
MARRIAGE
19. DATE COUPLE LAST RESIDED IN
20. NUMBER OF CHILDREN UNDER 18 IN THIS
21. PETITIONER
SAME HOUSEHOLD (Month, Day, Year)
HOUSEHOLD AS OF THE DATE IN ITEM 19.
Husband
Wife
Both
Number ___________
None
Other, Specify _________________
`
22a. NAME OF PETITIONER'S ATTORNEY (Type/Print)
22b. ADDRESS
(Street and Number or Rural Route Number, City or Town, State Zip Code)
ATTORNEY
`
23. I CERTIFY THAT THE MARRIAGE OF THE ABOVE
24. TYPE OF DECREE, Divorce, Dissolution,
25. DATE RECORDED
(Month, Day, Year)
NAMED PERSONS WAS DISSOLVED ON
or Annulment (Specify)
(Month, Day, Year)
26. NUMBER OF CHILDREN UNDER 18 WHOSE PHYSICAL CUSTODY
27. COUNTY OF DECREE
28. TITLE OF COURT
WAS AWARDED TO:
DECREE
Husband ______________________ Wife ______________________
Joint _________________________ Other _____________________
No Children
Not Determined Yet
29. SIGNATURE OF CERTIFYING OFFICIAL
30. TITLE OF CERTIFYING OFFICIAL 31. DATE SIGNED
(Month, Day, Year)
UDOH OVRS Form 14 Rev 12/03
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