Free Word - South Carolina

State of South Carolina Department of Health and Environmental Control

REPORT OF DIVORCE OR ANNULMENT OF MARRIAGE
State File No.
1. HUSBAND-NAME (First, Middle, Last, Suffix) 2. DATE OF BIRTH 3. PLACE OF BIRTH (State/Country)

4. RESIDENCE

(County, State/Country)

5. NUMBER OF THIS MARRIAGE - First, Second, etc. (Specify)

6. WIFE-MAIDEN NAME

(First, Middle, Last, Suffix)

7. DATE OF BIRTH

8. PLACE OF BIRTH (State/Country)

9. RESIDENCE

(County, State/Country)

10. NUMBER OF THIS MARRIAGE- First, Second, etc. (Specify)

11. PLACE OF THIS MARRIAGE (County, State/Country)

12. DATE OF MARRIAGE (MM/DD/YYYY)

13. PLAINTIFF Husband Wife 14. MAIDEN NAME RESUMED BY DECREE Yes No

15. NUMBER OF CHILDREN UNDER 18 INVOLVED IN THIS ACTION ________ No Children

16. DATE DECREE FILED (MM/DD/YYYY) 18. COUNTY

17. TYPE OF DECREE Absolute Divorce 19. DOCKET NUMBER Annulment

20. I CERTIFY THE MARRIAGE OF THE ABOVE NAMED PERSONS WAS DISSOLVED ON THE DATE DECREE FILED. SIGNATURE OF CLERK OF COURT: _______________________________________________ DATE SIGNED: ______________________ (MM/DD/YYYY)

Confidential and statistical information (The information below will not appear on certified copies of the report) 21. HUSBAND - SOCIAL SECURITY NUMBER 23. WIFE - SOCIAL SECURITY NUMBER 25. ATTORNEY FOR PLAINTIFF 27. LEGAL GROUNDS
DHEC 0682 (02/2008)

22. HUSBAND - RACE 24. WIFE - RACE 26. ATTORNEY BAR NUMBER