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