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.