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Rhode Island Department of Health Report of Divorce Form

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Rhode Island Department of Health Report of Divorce Form
Rhode Island Department of Health Report of Divorce Form
RHODE ISLAND DEPARTMENT OF HEALTH
REPORT OF DIVORCE
TYPE, OR PRINT IN
PERMANENT
BLACK INK
BRIEF
INSTRUCTIONS
ON REVERSE DOCKET NUMBER STATE FILE NUMBER
HUSBAND FIRST NAME
1a.
MIDDLE
1b.
LAST
1c.
MAILING ADDRESS OF RESIDENCE STREET OR R.F.D. AND NUMBER, CITY, TOWN, STATE, ZIP CODE
2a.
CITY OR TOWN OF RESIDENCE AND STATE
2b.
BIRTHPLACE (STATE OR FOREIGN COUNTRY)
3.
DATE OF BIRTH (Month, Day,
Year)
4a.
WIFE- FIRST NAME
5a.
MIDDLE
5b.
LAST
5c.
MAIDEN NAME
5d.
MAILING ADDRESS OF RESIDENCE- STREET OF R.F.D. AND NUMBER, CITY, TOWN, STATE, ZIP CODE
6a.
CITY OR TOWN OF RESIDENCE AND STATE
6b.
BIRTHPLACE (State or Foreign Country)
7.
DATE OF BIRTH (Month, Day, Year)
8a.
AGE (If D.O.B. unknown)
8b.
PLACE OF THIS MARRIAGE- City, Town & State or Foreign Country
9.
DATE OF THIS MARRIAGE (Month, Day, Year)
10.
DATE COUPLE LAST RESIDED IN SAME
HOUSEHOLD (Month, Day, Year)
11.
NUMBER OF CHILDREN UNDER 18 IN THS HOUSEHOLD
AS
OF THE DATE IN ITEM 11 (If none, enter a zero)
12.
PETITIONER-HUSBAND, WIFE, BOTH,
OTHER (SPECIFIY)
13.
NAME OF PETITIONERS ATTORNEY (TYPE/PRINT)
14.
ATTORNEY FOR PETITIONER- ADDRESS (Street and Number or Rural Route Number, City or Town, State, Zip Code)
15.
LEGAL GROUNDS FOR DECREE (Specify)
16.
DECREE GRANTE TO HUSBAND, WIFE,
OTHER (Specify)
17.
COUNTY OF DECREE
18.
DATE OF FINAL DECREE (Month, Day, Year)
19.
NUMBER OF CHILDREN UNDER 18 WHOSE PHYSICAL CUSTODY WAS
AWARDED TO:
20. Husband____________ Wife____________ Joint (Husband/Wife) ____________ Other____________ No Children
COURT OFFICIAL- SIGNATURE
21.
TITLE OF COURT OFFICIAL
22.
COURT- NAME
23.
INFORMATION FOR STATISTICAL PURPOSES ONLY
RACE- American Indian, Black,
White, etc. (Specify below)
24.
NUMBER OF THIS
MARRIAGE
First, Second, etc.
(Specify below)
25.
IF PREVIOUSLY MARRIED, LAST MARRIAGE ENDED
EDUCATION (Specify only highest grade
Completed.)
By Death, Divorce,
Dissolution, Or annulment.
(Specify below)
25a.
Date (Month, Day, Year)
26b.
Elementary or Secondary
(0-12)
27a.
College
(1-4 or 5+
27b.
RACE- American Indian, Black,
White, etc. (Specify below)
28.
NUMBER OF THIS
MARRIAGE
First, Second, etc.
(Specify below)
29.
IF PREVIOUSLY MARRIED, LAST MARRIAGE ENDED
EDUCATION (Specify only highest grade
Completed.)
By Death, Divorce,
Dissolution, Or annulment.
(Specify below)
30a.
Date (Month, Day, Year)
30b.
Elementary orSecondary
(0-12)
31a.
College
(1-4 or 5+)
31b.
HUSBAND
WIFE
DECREE
HUSBAND
WIFE
Rhode Island Department of Health Report of Divorce Form