1. County/Tribal Court 2. Court Record Number State of Nebraska Department of Health and Human Services Finance and Support Vital Records Certificate of Dissolution of Marriage or Annulment WORKSHEET ONLY 3. Husband's Name (First, Middle, Last, Suffix) 4a. Current Residence - Country 4b. State 4c. County 4d. City, Town or Location 4e. Residence - Street and Number 4f. Zip Code 5. Place of Birth (City and State or Foreign Country) 6. Date of Birth (Mo., Day, Yr.) 7a. Wife's Name (First, Middle, Last, Suffix) 8a. Current Residence - Country 8d. City, Town or Location 9. Place of Birth (City and State or Foreign Country) 11a. Place of Marriage - State 11b. County o W 8e. Residence - Street and Number s rk 8b. State e h 7b. Maiden Name t e 8c. County 8f. Zip Code 10. Date of Birth (Mo., Day, Yr.) 11c. City 11d. Date of Marriage (Mo., Day, Yr.) (Mo., Day, Yr.) 12a. Number of Children under 18 in this Household Number_______________________________ 13. Plaintiff Husband 12b. Number of Children Under 18 Whose Physical Custody was Awarded to: ______Husband ______Wife ______Joint Husband/Wife ______Other_________________________________________ No Children Awarded Custody 14. List Former Name of Wife, if restored Wife 15b. Address (Street, City or Town, State and Zip Code) 15a. Attorney for Plaintiff - Name 16a. I certify that the marriage of the above name persons was dissolved on 16b. Type of Decree (Mo., Day, Yr.) ______Dissolution ______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 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 Pacific Islander American LegalNet, Inc. www.FormsWorkFlow.com HHS-73 (55073) 6/06