STATE OF GEORGIA Report of Divorce, Annulment or Dissolution of Marriage Type or print all information 1. Civil Action Number 2. Date Decree Granted (mo., day, year) 3. County Decree Granted 4. Wife’s Name (first, middle, last) 5. Maiden (Birth) Last Name 6. Date of Birth (mo., day, year) 7. County of Residence 8. Number of This Marriage (1st, 2nd, etc.) 9. Husband’s Name (first, middle, last, generation) 10. Date of Birth (mo., day, year) 12. Number of This Marriage (1st, 2nd, etc.) 13. Date of This Marriage (mo., day, year) 14. Specify Grounds For Divorce (19-5-3, OCGA) 15. Number of Children Less Than 18 Affected by This Decree 11. County of Residence This above Report may be reproduced by use of a computer. However, the finished Report must be a close reproduction of the original, and prior review and approval must be obtained from the State Registrar before use. (31-10-7, O.C.G.A.) 31-10-22. Record of divorce, dissolutions, and annulments. (a) A record of each divorce, dissolution of marriage, or annulment granted by any court of competent jurisdiction in this state shall be filed by the clerk of the court with the department and shall be registered if it has been completed and filed in accordance with this Code section. The record shall be prepared by the petitioner or the petitioner’s legal representative on a form prescribed and furnished by the state registrar and shall be presented to the clerk of the court with the petition. In all cases, the completed record shall be a prerequisite to the granting of the final decree. (b) The clerk of the superior court shall complete and forward to the department on or before the tenth day of each calendar month the records of each divorce, dissolution of marriage, or annulment decree granted during the preceding calendar month. Form 3907 (Rev. 10-2002) American LegalNet, Inc. www.FormsWorkflow.com