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Fillable Printable Sample Certificate of Dissolution of Marriage - Missouri
Fillable Printable Sample Certificate of Dissolution of Marriage - Missouri
Sample Certificate of Dissolution of Marriage - 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.
HUSBAND
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.
WIFE
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
9b. COUNTY
9c. STATE FOREIGN COUNTRY
10. DATE OF THIS MARRIAGE
MARRIAGE
11. DATE COUPLE LAST RESIDED IN SAME
HOUSEHOLD
(Month, Day, Year)
12. NUMBER OF CHILDREN UNDER 18 IN THIS
HOUSEHOLD AS OF THE DATE IN ITEM 11
NUMBER : None
13. PETITIONER
0 Husband 1 Wife 2 Joint
3 Other
(Specify)
______________________________
ATTORNEY
14a. NAME OF PETITIONER’S ATTORNEY
Jayne A. Pearman
14b. ADDRESS (
Street and Number or Rural Route Number, City or Town, State, ZIP Code)
7007 College Boulevard, Suite 480
Overland Park, Kansas 66211
15. I CERTIFY THAT THE MARRIAGE OF THE ABOVE
-
NAMED
PERSONS WAS DISSOLVED ON: (
Month, Day, Year)
16. TYPE OF DECREE
0 Dissolution 1 Legal Separation 2 Annulment
17. DATE RECORDED
(M
onth, Day, Year)
DECREE
18. NUMBER OF CHILDREN UNDER 18
WHOSE PHYSICAL CUSTODY WAS
AWARDED TO:
Husband ________________ Wife______________
Joint
(Husband & Wife)
______________ Other______________
No children
19. CHILD SUPPORT WAS AWARDED TO:
1 Husband
2 Wife
4 Other
3 No child support awarded
20. COUNTY OF
DECREE
21. TITLE OF COURT
22. SIGNATURE OF CERTIFYING OFFICIAL
23. TITLE OF CERTIFYING OFFICIAL
24.
NO. OF THIS
MARRIAGE –
25.
PREVIOUSLY MARRIED, LAST MARRIAGE ENDED
26. RACE
-
America Indian, Black, White, etc.
(Specify below
)
27. EDUCATION
(Specify only
highest grade completed)
By:
Date:
(Month, Year)
HUSBAND
24a.
25a. 2
Death
3 Divorce,
dissolution
or annulment
25c.
26A 1 White 3 American Indian
2 Black 4 Other _______________
Elem/Sec
-
0/12
College
(1,2+)
27a
.
WIFE
24b.
25b. 2
Death
3 Divorce,
dissolution
or annulment
25d.
26B 1 White 3 American Indian
2 Black 4 Other _______________
27b.
