State of Florida Department of Health - Office of Vital Statistics APPLICATION FOR FLORIDA DISSOLUTION OF MARRIAGE REPORT (DIVORCE OR ANNULMENT) GRANTED IN FLORIDA (FOR APOSTILLE or EXEMPLIFIED CERTIFICATION) The Office of Vital Statistics does not forward records to the Department of State (DOS) for the DOS Apostille/Exemplified Certification process. If an apostille or exemplified certification from the DOS is needed, forward the record received from this application to the DOS. See the back of this application for DOS's mailing, street and website addresses and telephone number. Use this application when requesting certification from our office to ensure the correct certification needed for forwarding to the DOS for the apostille/exemplified certification process. SECTION A ­ REGISTRANT INFORMATION *NAME OF SPOUSE FIRST Please provide as much information as is known to you. Asterisk (*) items are REQUIRED fields. MIDDLE LAST INCLUDING SUFFIX MAIDEN, IF DIFFERENT DATE OF BIRTH (If known) *NAME OF SPOUSE FIRST MIDDLE LAST INCLUDING SUFFIX MAIDEN, IF DIFFERENT DATE OF BIRTH (If known) *DATE OF EVENT MONTH DAY YEAR (4-DIGIT) ADDITIONAL YEARS TO BE SEARCHED LIST SPAN OF YEARS TO SEARCH (ONLY if you do not know the exact year of the event) STATE FILE NUMBER (If known) CITY OR COUNTY WHERE DISSOLUTION GRANTED (If known) *COUNTRY WHERE CERTIFICATE TO BE USED (Required to ensure you receive the correct type of certification) CORRECTED or AMENDED Has the Clerk of Court corrected/amended an item on this Dissolution of Marriage Report (Divorce or Annulment) and forwarded the newly corrected Record to the Office of Vital Statistics? Yes No SECTION B ­ FEES& PAYMENT The $5.00 fee entitles the applicant to one Certification of Dissolution of Marriage Report (Divorce or Annulment) from June 1927 to present or if a record is not found, a certified "Not Found" statement will be issued. The Certification of Dissolution of Marriage Report is recognized and accepted by ALL State and Federal Agencies. $5.00 X 1 No. Certs. = $5.00 Additional Certifications: $4.00 for each subsequent Computer Certification Additional Years to be Searched: Required ONLY when the exact year of the divorce is not known and you wish more than one year searched. $2.00 for each additional year. The maximum additional year search fee is $ 50.00 regardless of the total number of years to be searched. (Indicate the range of years to be searched in Section A above.) $4.00 X No. of Yrs. = $ $2.00 X = $ RUSH ORDERS (Optional): RUSH fee will expedite your request within our office by prioritizing your request. Certification(s) will be mailed 1st class mail UNLESS a prepaid self-addressed envelope is included with our request. Check here for RUSH Order (Processing time within our office for Rush Service is 2-3 business days; routine processing time within our office is 4-6 business days.) TOTAL AMOUNT ENCLOSED: Check or Money Order Payable to: Vital Statistics. (DO NOT SEND CASH) International payments should be made by Cashiers Check or Money Order in U. S. Dollars. Florida Law imposes an additional service charge of $15.00 for dishonored checks. SECTION C ­ APPLICANT/MAILING INFORMATION $ $ Any person who willfully and knowingly provides any false information on a certificate, record or report required by Chapter 382, Florida Statutes, or on any application or affidavit, or who obtains confidential information from any Vital Record under false or fraudulent purposes, commits a felony of the third degree, punishable as provided in Chapter 775, Florida Statutes Applicant's Name TYPE OR PRINT DELIVERY ADDRESS (INCLUDE APT. NO., IF APPLICABLE) CITY STATE ZIP CODE FIRST MIDDLE LAST (INCLUDING ANY SUFFIX) HOME PHONE NUMBER ( ( ) ) WORK PHONE NUMBER IF ATTORNEY, PROVIDE BAR/PROFESSIONAL LICENSE NO. RELATIONSHIP TO REGISTRANT SIGNATURE OF APPLICANT IF ATTORNEY , PROVIDE NAME OF PERSON YOU REPRESENT AND THEIR RELATIONSHIP TO REGISTRANT IF THE CERTIFICATION IS TO BE MAILED TO ANOTHER PERSON OR ADDRESS USE THE SPACES BELOW TO SPECIFY SHIP TO NAME AND ADDRESS. SHIP TO NAME TYPE OR PRINT HOME PHONE NUMBER ( ) WORK PHONE NUMBER ( ) CITY STATE ZIP CODE FIRST MIDDLE LAST (INCLUDING ANY SUFFIX) SHIP TO STREET ADDRESS (AND APT. NO. IF APPLICABLE) DH 260A (Apostille), 01/2015, Florida Administrative Code Rule 64V-1.0131 (Obsoletes Previous Editions) American LegalNet, Inc. www.FormsWorkFlow.com INFORMATION AND INSTRUCTIONS APPLICATION FOR FLORIDA DISSOLUTION OF MARRIAGE REPORT (DIVORCE OR ANNULMENT) GRANTED IN FLORIDA (FOR APOSTILLE or EXEMPLIFIED CERTIFICATION) An apostille is a certification provided under the Hague convention of 1961 for authenticating documents for use in foreign countries. An exemplified certification covers those countries which did not sign the Hague Treaty. The sole function of the apostille or exemplified certificate is to certify the authenticity of the signature on the document. In Florida, the apostille or exemplified certificate contains the original signature of the State Registrar and the Secretary of State. Once the certification is obtained, it should be forwarded to the Florida Department of State (DOS) for the Apostille/Exemplified Certification of the signature of Florida's State Registrar. The address for mailing to the DOS is: Department of State, Division of Corporations, Apostille Certification, P.O. Box 6800, Tallahassee, FL 32314-6800; telephone (850) 245-6945. For walk-in service or courier delivery, the address is Department of State, Division of Corporations, Apostille Certification, Clifton Building, 2661 Executive Center Circle, Tallahassee, FL 32301. See the website at www.dos.state.fl.us/ for information regarding their requirements, processing time, fees, etc. To access the correct area on the website, select Corporations, then Apostilles. Be sure to provide the name of the country where the certification is needed. REGISTRATION OF DIVORCE REPORTS: After a divorce has been recorded with the Clerk of Court, the Clerk sends a report to this office. If the dissolution (divorce) was recently granted, it generally takes up to 60 days to be received, registered and available for certification from our office. DISSOLUTION (DIVORCE) REPORTS: We ONLY have reports for period of June 6, 1927 to the present. Any divorces prior to June 6, 1927 are obtainable from the Clerk of the Court in the County where the divorce was granted. The report we issue is an abstract of information taken from the judgment whic