Free Vital Statistics form - Nebraska


File Size: 127.9 kB
Pages: 1
Date: February 15, 2008
File Format: PDF
State: Nebraska
Category: Divorce
Author: MHP
Word Count: 551 Words, 3,434 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.courts.state.nh.us/forms/vsform_civil_union.pdf

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State of New Hampshire
CASE NUMBER

Clear Form
STATE FILE NUMBER

CERTIFICATE OF CIVIL UNION DISSOLUTION LEGAL SEPARATION OR ANNULMENT

PETITIONER

This form must be word processed or typewritten. The following information will be completed by the petitioner as indicated and filed with the court prior to the hearing on the merits in accordance with court rules. 1a. Person A's Name ­ First Middle Last 1b. Maiden Surname (if 2. Person A's Gender applicable) Male Female 3a. Residence ­ City, Town or Location (at time of filing) 3b. County 3c. State 4. Birthplace (State or Foreign
Country)

5. Date of Birth
(MM/DD/YYYY)

6. Number of This Union or Marriage
(Specify first, second, etc.)

7. Social Security Number

8. If previously joined in marriage or civil union, how many ended by:
(do not include current civil union)

9. Education: (specify highest grade completed) Elementary or secondary
(0-12)

Death Divorce/Annulment Civil Union Dissolution
RESPONDENT 10a. Person B's Name ­ First

Number Number Number Middle Last

College (1-4 or 5+)

10b. Maiden Surname (if
applicable)

12a. Residence ­ City, Town or Location (at time of filing) 13. Birthplace (State or Foreign
Country)

12b. County

11. Person B's Gender Male Female 12c. State 16. Social Security Number

14. Date of Birth 15. Number of This Union or Marriage
(MM/DD/YYYY) (Specify first, second, etc.)

17. If previously joined in marriage or civil union, how many ended by: 18. Education: (specify highest grade completed)
(do not include current civil union)

Death Divorce/Annulment Civil Union Dissolution
CIVIL UNION

Number Number Number 19b. County

Elementary or secondary (0-12)

College (1-4 or 5+)

19. Place of this Civil Union ­
City/Town

19c. State (or foreign
country)

20. Date of this Civil Union
(MM/DD/YYYY)

21. Date couple last resided in same 22a. Number of Children Born Alive or 22b. Number of Children Under Age 18 in Adopted During This Civil Union this Household as of Date in Item 21 Household (MM/DD/YYYY)
ATTORNEY

23a. Name of Petitioner's Attorney or Pro-Se

23b. Address (Street and Number, City/Town, 23c. Date (this form completed by
State, Zip Code) attorney or Pro-Se) (MM/DD/YYYY)

BELOW THIS LINE TO BE COMPLETED BY THE COURT 24a. Date petition filed 24b. Cause for Filing with court Irreconcilable Differences (MM/DD/YYYY) Other (specify)
DECREE

25b. Date Decree Becomes Final:
(MM/DD/YYYY)

24c. A decree was entered: There was an: 25a. Type of Decree Uncontested Hearing Dissolution Contested Hearing Legal Separation Defaulted Hearing Annulment 26a. Name of Hearing Official: (first and last name) 26b.Official Capacity: Judge Marital Master

27a. Name to be Used by Person A After Dissolution: Same as Present (1a) Maiden (1b) Other (specify) 27b. Name to be Used by Person B After Dissolution: Same as Present (10a) Maiden (10b) Other (specify)

28. Decision Making 29a. Number of Children Under 30. Residential Responsibility for Child/Children Age 18 for Whom Residential Responsibility was: Shall Be With: Responsibility is With: Both Parents # Both Parents Uncontested Person A Person A # Contested Person B Defaulted Person B # Other (specify) Not Applicable Other (specify) # Not Applicable Not Applicable

31. Signature of Court Official: I certify that the above is correct to the best of my 31b. Court Name:
knowledge.

31c. Date Signed:
(MM/DD/YYYY)

SOS/DVRA VS 14Acu-08 Rev 02/2008

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