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Kansas Worksheet for Divorce or Annulment Registration Form


Kansas Worksheet for Divorce or Annulment Registration Form
Kansas Worksheet for Divorce or Annulment Registration Form
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. HUSBAND’S NAME (First, Middle, Last)
2. DATE OF BIRTH (Month, Day, Year)
3. RESIDENCE-STATE
4. COUNTY
5. WIFE’S NAME (First, Middle, Last)
6. WIFE’S 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 PETITIONER’S ATTORNEY (Type)
16. ATTORNEY’S 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. HUSBAND’S SOCIAL SECURITY NUMBER
22. WIFE’S 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 “no” 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. HUSBAND’S EDUCATION 8
th
grade or less 9
th
- 12
th
grade; no diploma High school graduate or GED
Some College credit, but no degree Associate degree (e.g., AA,AS) Bachelor’s degree (e.g., BA, AB, BS)
Unknown Master’s 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. WIFE’S EDUCATION 8
th
grade or less 9
th
- 12
th
grade; no diploma High school graduate or GED
Some College credit, but no degree Associate degree (e.g., AA,AS) Bachelor’s degree (e.g., BA, AB, BS)
Unknown Master’s degree (e.g., MA, MS, MEng, MEd, MSW, MBA) Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DDS, DVM, LLB, JD)
Kansas Worksheet for Divorce or Annulment Registration Form