STATE OF UTAH - DEPARTMENT OF HEALTH CERTIFICATE OF DIVORCE, DISSOLUTION OF MARRIAGE, OR ANNULMENT 1a. First Name 1e. Sex SPOUSE 1 1b. Middle Name 2a. RESIDENCE - CITY, TOWN OR LOCATION 1c. Last name before first marriage, if applicable 1d. Last Name 2b. COUNTY 4. BIRTHDATE (MM/DD/YY) 8. EDUCATION: (Specify only highest grade completed) Elementary/Secondary (0 - 12) College (13-16 or 17+) M 2c. STATE F 3. BIRTHPLACE (State or Foreign Country) 7. RACE: White, Black, American Indian, etc. (Specify) 5. NUMBER OF THIS MARRIAGE - First, Second, etc. (Specify) 6. IF NOT FIRST MARRIAGE, LAST MARRIAGE ENDED: By Death, Divorce, Dissolution, Date (MM/DD/YY) or annulment (Specify) 9a. First Name 9e. Sex 9b. Middle Name 10a. RESIDENCE - CITY, TOWN OR LOCATION 9c. Last name before first marriage, if applicable 9d. Last Name 10b. COUNTY 12. BIRTHDATE (MM/DD/YY) 16. EDUCATION: (Specify only highest grade completed) Elementary/Secondary (0 - 12) College (13-16 or 17+) M SPOUSE 2 F 11. BIRTHPLACE (State or Foreign Country) 15. RACE: White, Black, American Indian, etc. (Specify) 10c. STATE 13. NUMBER OF THIS MARRIAGE - First, Second, etc. (Specify) 14. IF NOT FIRST MARRIAGE, LAST MARRIAGE ENDED: By Death, Divorce, Dissolution, Date (MM/DD/YY) or annulment (Specify) 17a. PLACE OF THIS MARRIAGE - CITY TOWN, OR LOCATION MARRIAGE 17b. COUNTY 17c. STATE OR FOREIGN COUNTRY 21. PETITIONER 18. DATE OF THIS MARRIAGE (MM/DD/YY) 19. DATE COUPLE LAST RESIDED IN SAME HOUSEHOLD (MM/DD/YY) 20. NUMBER OF CHILDREN UNDER 18 IN THIS HOUSEHOLD AS OF THE DATE IN ITEM 19 Number_________ None Spouse 1 Spouse 2 Other, Specify ____________ Both ATTORNEY 22a. NAME OF PETITIONER'S ATTORNEY (Type/Print) 22b. ADDRESS (Street and Number or Rural Route Number, City, or Town, State, Zip Code) 23. I CERTIFY THAT THE MARRIAGE OF THE ABOVE NAMED PERSONS WAS DISSOLVED ON (MM/DD/YY) DECREE 24. TYPE OF DECREE, Divorce, Dissolution, or Annulment (Specify) 27. COUNTY OF DECREE 25. DATE RECORDED (MM/DD/YY) 26. NUMBER OF CHILDREN UNDER 18 WHOSE PHYSICAL CUSTODY WAS AWARDED TO: Spouse 1_______ Spouse 2_______ Joint__________ Other _________ No Children Not Determined Yet 29. SIGNATURE OF CERTIFYING OFFICIAL 28. TITLE OF COURT 30. TITLE OF CERTIFYING OFFICIAL 25. DATE SIGNED (MM/DD/YY) UDOH OVRS Form 404 Rev. 01/16 American LegalNet, Inc. www.FormsWorkFlow.com