Utah Certificate of Divorce Form

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
2c. STATE
HUSBAND
2b. COUNTY
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)
7. RACE: White, Black, 8. EDUCATION: (Specify only
highest grade completed)
Amer. Indian, etc.
Elementary/Secondary
College
(Specify below)
9a. WIFE'S NAME (First, Middle, Last)
9b. MAIDEN LAST NAME
(0 - 12)
10a. RESIDENCE - CITY, TOWN OR LOCATION
10c. STATE
WIFE
11. BIRTHPLACE (State or Foreign Country)
MARRIAGE
17a. PLACE OF THIS MARRIAGE - CITY,
TOWN, OR LOCATION
(13-16 or 17+)
10b. COUNTY
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)
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4. DATE OF BIRTH (Month, Day, Year)
17b. COUNTY
12. DATE OF BIRTH (Month, Day, Year)
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+)
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 ___________
21. PETITIONER
None
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22a. NAME OF PETITIONER'S ATTORNEY (Type/Print)
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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)
Husband
Wife
Both
Other, Specify _________________
22b. ADDRESS (Street and Number or Rural Route Number, City or Town, State Zip Code)
ATTORNEY
DECREE
26. NUMBER OF CHILDREN UNDER 18 WHOSE PHYSICAL CUSTODY
WAS AWARDED TO:
25. DATE RECORDED (Month, Day, Year)
27. COUNTY OF DECREE 28. TITLE OF COURT
Husband ______________________ Wife ______________________
Joint _________________________ Other _____________________
No Children
Not Determined Yet
29. SIGNATURE OF CERTIFYING OFFICIAL
UDOH OVRS Form 14 Rev 12/03
30. TITLE OF CERTIFYING OFFICIAL
31. DATE SIGNED
(Month, Day, Year)