ID Requirements TENNESSEE DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS APPLICATION FOR CERTIFIED COPY OF CERTIFICATE OF DIVORCE OR ANNULMENT Today’s Date: Number of copies First Copy $15.00, each additional copy $5.00 Name of Husband: First Middle Last Name First Middle Maiden Name Month Day Year City County State Name of Wife: Date of Divorce: Place of Divorce: Signature of Person Making Request: Relationship of Requestor: Purpose of Copy: Telephone number where you may be reached for additional information: ( ) IT IS UNLAWFUL TO WILLFULLY AND KNOWINGLY MAKE ANY FALSE STATEMENT ON THIS APPLICATION. Records are filed in this office for the past fifty (50) years. Records prior to this date are available from the clerk of the court where the divorce was granted and may be available from the State Library and Archives. A fee of $15.00 is charged for the search of the records even if no record is found and includes one copy if the record is filed in this office. If the certificate is not found with the date of divorce that you provide, a search will be made in the records for the year before and the year after the date indicated; this search is routine and is included in the fee. Do not send cash. Send a check or money order made payable to Tennessee Vital Records. In addition, unless this application is notarized, you must send a photocopy of a government issued ID showing your signature. If you have not received a response within 45 days, please write or call Tennessee Vital Records at 615- 741-1763. PH-1671 (rev. 11/2008) RDA N/A FILL OUT BELOW/ DO NOT DETACH Name and address of person to whom the certified copy is to be mailed. (Please Print) SEND TO: Name Tennessee Vital Records Address or Route, Include Apartment Number 421 5th Avenue North 1st floor, Central Services Building Nashville, TN 37243 City State Zip Code American LegalNet, Inc. www.FormsWorkFlow.com