Fillable Printable Certificate of Dissolution of Marriage Example - Missouri

Certificate of Dissolution of Marriage Example - Missouri

MISSOURI DEPARTMENT OF HEALTH

CERTIFICATE OF DISSOLUTION OF MARRIAGE

CASE NUMBER STATE FILE NUMBER

1. HUSBAND’S NAME (First, Middle, Last) 1a. SOCIAL SECURITY NO.

2a. RESIDENCE – CITY, TOWN, OR LOCATION 2b. STATE 2c. ZIP CODE

2d. COUNTY 3. DATE OF BIRTH (Month, Day, Year) 4. BIRTHPLACE (State or Foreign Country)

5a. WIFE’S NAME (First, Middle, Last) 5b. MAIDEN SURNAME 5c. SOCIAL SECURITY NO.

6a. RESIDENCE – CITY, TOWN, OR LOCATION 6b. STATE 6c. ZIP CODE

6d. COUNTY 7. DATE OF BIRTH (Month, Day, Year) 8. BIRTHPLACE (State or Foreign Country)

9a. PLACE OF THIS MARRIAGE – CITY, TOWN OR LOCATION 9b. COUNTY 9c. STATE OR FOREIGN COUNTRY 10. DATE OF THIS MARRIAGE

(Month, Day, Year)

11. DATE COUPLE LAST RESIDED IN SAME 12. NUMBER OF CHILDREN UNDER 18 IN THIS HOUSEHOLD AS OF 13. PETITIONER

HOUSEHOLD (Month, Day, Year) THE DATE IN ITEM 11

0 □ Husband 1 □ Wife 2 □ Joint

Number _____________ □ None 3 □ Other (Specify) __________________________

14a. NAME OF PETITIONER’S ATTORNEY (Type or Print) 14b. ADDRESS (Street and Number or Rural Route Number, City or Town, State, Zip code)

15. I CERTIFY THAT THE MARRIAGE OF THE ABOVE-NAMED 16. TYPE OF DECREE 17. DATE RECORDED (Month, Day, Year)

PERSONS WAS DISSOLVED ON:

(Month, Day, Year) 0 □ Dissolution 1 □ Legal Separation 2 □ Annulment

18. NUMBER OF CHILDREN UNDER 18 WHOSE PHYSICAL CUSTODY WAS 19. CHILD SUPPORT WAS AWARDED 20. COUNTY OF DECREE 21. TITLE OF COURT

AWARDED TO: TO:

1 □ Husband

Husband ___________________ Wife __________ 2 □ Wife St. Louis 21st Circuit

Joint (Husband/Wife) __________ Other ____________ 4 □ Other

□ No children 3 □ No child support awarded

22. SIGNATURE OF CERTIFYING OFFICIAL 23. TITLE OF CERTIFYING OFFICIAL

► Circuit Clerk

24. NUMBER OF THIS 25. IF PREVIOUSLY MARRIED, LAST MARRIAGE ENDED 27. EDUCATION

MARRIAGE – 26. RACE – American Indian, Black, White, etc. (Specify only highest grade completed)

First, Second, etc. By: Date: (Month, Year) (Specify below) Elementary/Secondary College

(Specify below) (0-12) (1-4 or 5+)

24a. 25a. 25c. 26a. 1 □ White 27a.

2 □ Death 2 □ Black

3 □ Divorce, dissolution, 3 □ American Indian

or annulment 4 □ Other (Specify) __________________

24b. 25b. 25d. 26b. 1 □ White 27b.

2 □ Death 2 □ Black

3 □ Divorce, dissolution, 3 □ American Indian

or annulment 4 □ Other (Specify)__________________

VS 800

Rev. 6/97

MO 580-0716

(6/97)

TYPE/PRINT

PERMANENT

BLACK INK.

FOR

INSTRUCTIONS

SEE HANDBOOK

HUSBAND

WIFE

MARRIAGE

ATTORNEY

DECREE

HUSBAND

WIFE

CCFC65 Rev. 9/04 WHITE – Vital Statistics YELLOW - File