Free CERTIFICATE OF DIVORCE, DISSOLUTION OF MARRIAGE, OR ANNULMENT - Utah

STATE OF UTAH - DEPARTMENT OF HEALTH CERTIFICATE OF DIVORCE, DISSOLUTION OF MARRIAGE, OR ANNULMENT
1. HUSBAND'S NAME (First, Middle, Last) 2a. RESIDENCE - CITY, TOWN OR LOCATION
HUSBAND

2b. COUNTY 4. DATE OF BIRTH (Month, Day, Year)

2c. STATE

3. BIRTHPLACE (State or Foreign Country)

5. NUMBER OF THIS 6. IF NOT FIRST MARRIAGE, LAST MARRIAGE ENDED: MARRIAGE First, Second, etc. By Death, Divorce, Dissolution, Date (Mo., Day, Yr.) (Specify below) or Annulment (Specify Below) 9a. WIFE'S NAME (First, Middle, Last) 10a. RESIDENCE - CITY, TOWN OR LOCATION
WIFE

7. RACE: White, Black, 8. EDUCATION: (Specify only highest grade completed) Amer. Indian, etc. Elementary/Secondary College (Specify below)
(0 - 12)

(13-16 or 17+)

9b. MAIDEN LAST NAME 10b. COUNTY 12. DATE OF BIRTH (Month, Day, Year)

10c. STATE

11. BIRTHPLACE (State or Foreign Country)

13. NUMBER OF THIS 14. IF NOT FIRST MARRIAGE, LAST MARRIAGE ENDED: MARRIAGE First, Second, etc. By Death, Divorce, Dissolution, Date (Mo., Day, Yr.) (Specify below) or Annulment (Specify Below)

15. RACE: White, Black,16. EDUCATION: (Specify only highest grade completed) Amer. Indian, etc. Elementary/Secondary College (Specify below)
(0 - 12)

(13-16 or 17+)

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MARRIAGE

17a. PLACE OF THIS MARRIAGE - CITY, TOWN, OR LOCATION

17b. COUNTY

17c. STATE OR FOREIGN COUNTRY18. DATE OF THIS MARRIAGE (Month, Day, Year)

19. DATE COUPLE LAST RESIDED IN 20. NUMBER OF CHILDREN UNDER 18 IN THIS SAME HOUSEHOLD (Month, Day, Year) HOUSEHOLD AS OF THE DATE IN ITEM 19. Number ___________ None

21. PETITIONER Husband Wife Both Other, Specify _________________

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ATTORNEY

22a. NAME OF PETITIONER'S ATTORNEY (Type/Print)

22b. ADDRESS (Street and Number or Rural Route Number, City or Town, State Zip Code)

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23. I CERTIFY THAT THE MARRIAGE OF THE ABOVE 24. TYPE OF DECREE, Divorce, Dissolution, NAMED PERSONS WAS DISSOLVED ON or Annulment (Specify) (Month, Day, Year)

25. DATE RECORDED (Month, Day, Year)

DECREE

26. NUMBER OF CHILDREN UNDER 18 WHOSE PHYSICAL CUSTODY WAS AWARDED TO: Husband ______________________ Wife ______________________ Joint _________________________ Other _____________________ No Children Not Determined Yet

27. COUNTY OF DECREE 28. TITLE OF COURT

29. SIGNATURE OF CERTIFYING OFFICIAL

30. TITLE OF CERTIFYING OFFICIAL

31. DATE SIGNED

(Month, Day, Year)

UDOH OVRS Form 14 Rev 12/03