State of South Carolina Department of Health and Environmental Control REPORT OF DIVORCE OR ANNULMENT OF MARRIAGE State File No. 1. PLAINTIFF (First, Middle, Last, Suffix) 2. LAST NAME ON BIRTH CERTIFICATE (If Different) 3. DATE OF BIRTH (Month, Day, Year) 4. PLACE OF BIRTH (State or Foreign Country) 5. RESIDENCE (County, State/Country) 6. NUMBER OF THIS MARRIAGE - First, Second, etc. (Specify) 7. DEFENDANT (First, Middle, Last, Suffix) 8. LAST NAME ON BIRTH CERTIFICATE (If Different) 9. DATE OF BIRTH (Month, Day, Year) 10. PLACE OF BIRTH (State or Foreign Country) 11. RESIDENCE (County, State/Country) 12. NUMBER OF THIS MARRIAGE- First, Second, etc. (Specify) 13. PLACE OF THIS MARRIAGE (County, State/Country) 15. TYPE OF DECREE Absolute Divorce Annulment 14. DATE OF MARRIAGE (mm/dd/yyyy) 17. DOCKET NUMBER 16. COUNTY OF DECREE 18. DATE DECREE FILED (mm/dd/yyyy) - TO BE COMPLETED BY CLERK OF COURT. 19. I CERTIFY THE MARRIAGE OF THE ABOVE NAMED PERSONS WAS DISSOLVED ON THE DATE DECREE FILED. SIGNATURE OF CLERK OF COURT: _______________________________________________ DATE SIGNED: ______________________ (mm/dd/yyyy) Confidential and statistical information (The information below will not appear on certified copies of the report) 20. PLAINTIFF - SOCIAL SECURITY NUMBER (Last 4 Digits) 23. DEFENDANT - SOCIAL SECURITY NUMBER (Last 4 Digits) 26. ATTORNEY FOR PLAINTIFF 28. LEGAL GROUNDS DHEC 0682 (09/2015) 21. PLAINTIFF - RACE 24. DEFENDANT - RACE 27. ATTORNEY BAR NUMBER 22. PLAINTIFF - SEX 25. DEFENDANT - SEX American LegalNet, Inc. www.FormsWorkFlow.com