VS243 Rev.04/07/04 KANSAS DEPARTMENT OF HEALTH AND ENVIRONMENT Office of Vital Statistics WORKSHEET FOR DIVORCE OR ANNULMENT REGISTRATION This worksheet is to be completed by the prevailing party or the legal representative of the prevailing party and returned to the district court before the divorce or annulment can be filed. This information will be used by the clerk of the court to complete the official divorce or annulment certificate (report). This worksheet is not to be forwarded to the Office of Vital Statistics. 1. HUSBAND222S NAME (First, Middle, Last) 2. DATE OF BIRTH (Month, Day, Year) 3. RESIDENCE-STATE 4. COUNTY 5. WIFE222S NAME (First, Middle, Last) 6. WIFE222S LAST NAME PRIOR TO FIRST MARRIAGE 7. DATE OF BIRTH (Month, Day, Year) 8. RESIDENCE-STATE 9. COUNTY 10. PLACE OF THIS MARRIAGE - STATE OR FOREIGN COUNTRY 11. COUNTY 12. DATE OF THIS MARRIAGE (Month, Day, Year) 13. NUMBER OF CHILDREN UNDER 18 IN THIS HOUSEHOLD AS OF DATE IN ITEM 17 14. PETITIONER Husband Wife Both Other (Specify) 15. NAME OF PETITIONER222S ATTORNEY (Type) 16. ATTORNEY222S ADDRESS (Street and Number or Rural Route, City or Town, State, Zip Code) 17. DATE DECREE FILED (Month, Day, Year) 18. TYPE OF DECREE-(Specify) Divorce Annulment 19. COUNTY OF DECREE 20. CASE NUMBER THE INFORMATION BELOW WILL NOT APPEAR ON CERTIFIED COPIES OF THE RECORD. K.S.A. 65-2422B, REQUIRES THE DIVORCE REPORT TO INCLUDE THE SOCIAL SECURITY NUMBER OF BOTH PARTIES TO MAKE SUCH INFORMATION AVAILABLE TO THE SECRETARY OF SOCIAL AND REHABILITATION SERVICES FOR THE PURPOSE OF ESTABLISHING, MODIFYING, OR ENFORCING A SUPPORT OBLIGATION. 21. HUSBAND222S SOCIAL SECURITY NUMBER 22. WIFE222S SOCIAL SECURITY NUMBER 24. IF PREVIOUSLY MARRIED, LAST MARRIAGE ENDED 23. NUMBER OF THIS MARRIAGE First, Second, etc. (Specify below) By Death, Divorce, or Annulment (Specify below) Date (Month, Day, Year) 23a. HUSBAND 24a. HUSBAND 24b HUSBAND 23b. WIFE 24c. WIFE 24d. WIFE 26. RACE (Check one or more boxes to indicate what race(s) you consider yourself to be.) 25. HISPANIC ORIGIN (Check the box or boxes that best describes whether you are Spanish, Hispanic, or Latino. Check the 223no224 box if you are not Spanish, Hispanic, or Latino.) 25a. HUSBAND No, not Spanish/ Hispanic/Latino Yes, Mexican/Mexican American/Chicano Yes, Puerto Rican Yes, Cuban Yes, Central American Yes, South American Yes, other Spanish/ Hispanic/Latino (Specify) Unknown 25b. WIFE No, not Spanish/ Hispanic/Latina Yes, Mexican/Mexican American/Chicana Yes, Puerto Rican Yes, Cuban Yes, Central American Yes, South American Yes, other Spanish/ Hispanic/Latina (Specify) Unknown 26a. HUSBAND White Korean Black or Vietnamese African American American Indian or Other Asian (Specify) Alaska Native (Name of the enrolled or principal tribes) Native Hawaiian Asian Indian Guamanian or Chamorro Chinese Samoan Filipino Other Pacific Islander (Specify) Japanese Other (Specify) Unknown 26b. WIFE White Korean Black or Vietnamese African American American Indian or Other Asian (Specify) Alaska Native (Name of the enrolled or principal tribes) Native Hawaiian Asian Indian Guamanian or Chamorro Chinese Samoan Filipino Other Pacific Islander (Specify) Japanese Other (Specify) Unknown 27. EDUCATION (Check the box that best describes the highest degree or level of school completed.) 27a. HUSBAND222S EDUCATION 8th grade or less 9th - 12th grade; no diploma High school graduate or GED Some College credit, but no degree Associate degree (e.g., AA,AS) Bachelor222s degree (e.g., BA, AB, BS) Unknown Master222s degree (e.g., MA, MS, MEng, MEd, MSW, MBA) Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DDS, DVM, LLB, JD) 27b. WIFE222S EDUCATION 8th grade or less 9th - 12th grade; no diploma High school graduate or GED Some College credit, but no degree Associate degree (e.g., AA,AS) Bachelor222s degree (e.g., BA, AB, BS) Unknown Master222s degree (e.g., MA, MS, MEng, MEd, MSW, MBA) Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DDS, DVM, LLB, JD) American LegalNet, Inc. www.FormsWorkFlow.com