Oregon Record of Dissolution of Marriage, Annulment, or Registered Domestic Partnership-REQUIRED Form
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PUBLIC HEALTH DIVISION
Center for Health Statistics
RECORD OF DISSOLUTION
OF MARRIAGE, ANNULMENT OR
REGISTERED DOMESTIC PARTNERSHIP
136-
State 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.Husband/Partner A – Legal name:(first, middle, last, suffix)
2.Last name at birth: (not required for RDP)
Husband /
Partner A
3.Residence or legal address: (street and number) (city or town) (county) (state)
4.Other legal last names used:
5.Date of birth: (mm/dd/yyyy)
6.Birthplace: (state, territory or foreign country)
7.Wife/Partner B – Legal name:(first, middle, last, suffix)
8.Last name at birth: (not required for RDP)
Wife /
Partner B
9.Residence or legal address: (street and number) (city or town) (county) (state)
10.Other legal last names used:
11.Date of birth: (mm/dd/yyyy)
12.Birthplace: (state, territory or foreign country)
13. Date of marriage / filing of RDPdeclaration: (mm/dd/yyyy)
14.Date couple last resided in same household: (mm/dd/yyyy)
Marriage /
Declaration
15a.Place of marriage/RDP:(city, town or location)
15b.County:
15c.State or foreign country:
16. Number of children under 18 in this household as of the date in item 14:
Number:None
17.Petitioner:
Husband/Partner A Wife/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)
Attorney
19a.Name of respondent’s attorney:
(print)
19b.Address:
(street and number or rural route number, city or town, state, ZIP code)
20.Marriage/RDPdeclaration of the above named persons was
dissolved on: (mm/dd/yyyy)
21.Date judgmentbecomes effective: (mm/dd/yyyy)
Judgment
22.Number of children under 18 whose physical custody was awarded to:
Husband/Partner AWife/Partner B Joint (shared custody)Other(specify)No children
23.County of decree:
24. Title of court:
Circuit
25.Signature of court official:
26.Title of court official:
27.Date signed: (mm/dd/yyyy)
Information below will not appear on the certified copies of the record.
28.Husband’s Social Security number: (not required for RDP)
29.Wife’sSocial Security number:(not required for RDP)