PUBLIC HEALTH DIVISION Center for Health Statistics RECORD OF DISSOLUTION OF MARRIAGE, ANNULMENT OR REGISTERED DOMESTIC PARTNERSHIP 136State file number: The petitioner or legal representative of the petitioner is responsible for completing the personal information on this form and shall present this form 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 judgment. Case number: Judgment type: Dissolution of marriage Annulment Dissolution of registered domestic partnership(RDP) 1. Spouse/Partner A ­ Legal name: Spouse / Partner A 3. Residence or legal address: 4. Other legal last names used: 5. Date of birth: (mm/dd/yyyy) 7. Spouse/Partner B ­ Legal name: Spouse / Partner B 9. Residence or legal address: 10. Other legal last names used: 11. Date of birth: (mm/dd/yyyy) (first, middle, last, suffix) (city or town) 2. Last name at birth: (not required for RDP) (county) (state) (street and number) 6. Birthplace: (state, territory or foreign country) (first, middle, last, suffix) (city or town) 8. Last name at birth: (not required for RDP) (county) (state) (street and number) 12. Birthplace: (state, territory or foreign country) 14. Date couple last resided in same household: (mm/dd/yyyy) 15c.State or foreign country: 17. Petitioner: 13. Date of marriage / filing of RDP declaration: (mm/dd/yyyy) Marriage / Declaration 15a.Place of marriage/RDP: (city, town or location) 15b.County: 16. Number of children under 18 in this household as of the date in item 14: Number: Attorney 19a.Name of respondent's attorney: (print) None Spouse/Partner A Spouse/Partner B Both 18a.Name of petitioner's attorney: (print) 18b. Address: (street and number or rural route number, city or town, state, ZIP code) 19b. Address: (street and number or rural route number, city or town, state, ZIP code) Judgment 20. Marriage/RDP declaration of the above named persons was dissolved on: (mm/dd/yyyy) 21. Date judgment becomes effective: (mm/dd/yyyy) 22. Number of children under 18 whose physical custody was awarded to: Spouse/Partner A 23. County of decree: 25. Signature of court official: Spouse/Partner B Joint (shared custody) Other (specify) 24. Title of court: No children Circuit 26. Title of court official: 27. Date signed: (mm/dd/yyyy) Information below will not appear on the certified copies of the record. 28. Spouse A's Social Security number: (not required for RDP) 30. Number of this 31. If previously married or in a marriage/RDP ­ RDP date last marriage/RDP first, second, etc.: ended: Marriage 30a. RDP 30b. By death, divorce, dissolution or annulment (specify below) 31a. Date: (mm/dd/yyyy) 31b. 29. Spouse B's Social Security number: (not required for RDP) 34. Education ­ Specify only highest grade completed: Elementary/Secondary: (grades 0-12) 34a. College: (1-4 or 5+) 34b. 32. Hispanic origin: 33. Race(s): Black, Cuban, Mexican, White, etc. Puerto Rican List all that apply (specify below) 32a. List all that apply (specify below) 33a. Spouse / Partner A Spouse / Partner B 30c. 30d. 31c. 31d. 32b. 33b. 34c. 34d. American LegalNet, Inc. www.FormsWorkFlow.com 4512 (08/14)