Fillable Printable Certification of Divorce, Dissolution of Marriage or Annulment - Utah
Fillable Printable Certification of Divorce, Dissolution of Marriage or Annulment - Utah
Certification of Divorce, Dissolution of Marriage or Annulment - Utah
STATE OF UTAH - DEPARTMENT OF HEALTH
CERTIFICATE OF DIVORCE, DISSOLUTION
OF MARRIAGE, OR ANNULMENT
2a. RESIDENCE - CITY, TOWN OR LOCATION 2b. COUNTY
2c. STATE 3. BIRTHPLACE (State or Foreign Country) 4. BIRTHDATE (MM/DD/YY)
5. NUMBER OF THIS
MARRIAGE - First,
Second, etc. (Specify)
7. RACE: White, Black, American
Indian, etc. (Specify)
8. EDUCATION: (Specify only highest
grade completed)
Elementary/Secondary
(0 - 12)
College
(13-16 or 17+)
10b. COUNTY10a. RESIDENCE - CITY, TOWN OR LOCATION
15. RACE: White, Black, American
Indian, etc. (Specify)
Date (MM/DD/YY)By Death, Divorce, Dissolution,
or annulment (Specify)
14. IF NOT FIRST MARRIAGE, LAST MARRIAGE ENDED:
13. NUMBER OF THIS
MARRIAGE - First,
Second, etc. (Specify)
12. BIRTHDATE (MM/DD/YY)11. BIRTHPLACE (State or Foreign Country)10c. STATE
College
(13-16 or 17+)
Elementary/Secondary
(0 - 12)
16. EDUCATION: (Specify only highest
grade completed)
6. IF NOT FIRST MARRIAGE, LAST MARRIAGE ENDED:
Date (MM/DD/YY)
By Death, Divorce, Dissolution,
or annulment (Specify)
17a. PLACE OF THIS MARRIAGE - CITY TOWN, OR LOCATION 17b. COUNTY 17c. STATE OR FOREIGN COUNTRY 18. DATE OF THIS MARRIAGE
(MM/DD/YY)
19. DATE COUPLE LAST RESIDED IN SAME HOUSEHOLD
(MM/DD/YY)
20. NUMBER OF CHILDREN UNDER 18 IN THIS
HOUSEHOLD AS OF THE DATE IN ITEM 19
Number_________
None
21. PETITIONER
Spouse 1 BothSpouse 2
Other, Specify ____________
22a. NAME OF PETITIONER'S ATTORNEY (Type/Print) 22b. ADDRESS (Street and Number or Rural Route Number, City, or Town, State, Zip Code)
SPOUSE 1SPOUSE 2 MARRIAGE ATTORNEY DECREE
23. I CERTIFY THAT THE MARRIAGE OF THE ABOVE NAMED PERSONS
WAS DISSOLVED ON (MM/DD/YY)
24. TYPE OF DECREE, Divorce, Dissolution,
or Annulment (Specify)
25. DATE RECORDED (MM/DD/YY)
28. TITLE OF COURT27. COUNTY OF DECREE26. NUMBER OF CHILDREN UNDER 18 WHOSE PHYSICAL CUSTODY WAS AWARDED TO:
Spouse 1_______ Spouse 2_______ Joint__________ Other _________
Not Determined YetNo Children
25. DATE SIGNED (MM/DD/YY)30. TITLE OF CERTIFYING OFFICIAL29. SIGNATURE OF CERTIFYING OFFICIAL
UDOH OVRS Form 404 Rev. 01/16
1d. Last Name1c. Last name before first marriage,
if applicable
1b. Middle Name1a. First Name
9d. Last Name9c. Last name before first marriage,
if applicable
9b. Middle Name9a. First Name
1e. Sex
FM
9e. Sex
FM
