Virginia VS-4 Statistical Reporting form

Download

VS-4 Statistical Reporting Form

This form transfers the divorce information to the department of health in Virginia in order for their records.

Preview

NOTE:

ITEMS 1·24 ON THIS

FORM TO BE

COMPLETED BY

PETITIONER OR

ATTORNEY AND FILED

Wl1l4 CLERK OF COURT

WITH PETITION OR

DECREE

PLEASE PREPARE BY

TYPEWRITER OR PRINT

IN BLACK UNFADING INK

THIS IS A PERMANENT

RECORD.

CLERK OF COURT WILL

CERTIFY AND FORWARD

TO STATE REGISTRAR BY

10TH DAY OF MONTH

FOLLOWING DATE FINAL

DECREE IS GRANTED.

SECTION 32.1·281

CODE OF VIRGINIA

APPENDIXM

COMMONWEALTH OF VIRGINIA- REPORT OF DIVORCE OR ANNULMENT

Department of  Health – Division of VItal Recorda – Richmond

1. CIRCUIT COURT FOR CITY OR COUNTY OF I STATEFILE

NUMBER

2. FULL ~2A. SOCIAL SECURITY I

NAME

3. PI.ACEOF (,.,. CK tot./gtl ctNI’IIIy) 4. DATE OF

BIRTH BIRTH

5. RACE I 6. NUMBER OF (flm, -.d. etc.) 7. EDUCATION a.n-tary CK s-Jdary I HUSBAND THIS MARRIAGE (Sprlcify only ltig/IHI (0-12} I (1~

~~) I

8. USUAL (.net no. or rulal tt:IIM no.) (city CK town) (=unty-H not • ..,..,., city) (,.,.)

RESIDENCE

9. FULL MAIDEN .. 19A. SOCIAL SECURITY I

NAME

10. PlACE OF ( .. te CK ltWign ctNI’IIIy) 11. DATE OF

BIRTH BIRTH

12. RACE 113. NUM8ER OF {flm, -.d, etc.) 14. EDUCAnON a.n-tary or Secondary I Colleg

WIFE THIS MARRIAGE ~onlyltig/IHI (0.12) II (1-4 or~

15. USUAL (.net no. or~~ tt:IIM no.) (city or town) (county-If not • ..,..,., clfy) t•teJ

RESIDENCE

18. PlACE OF (cily or townl 1_,.,1 t•te or foreign coun1ryl 17. DATE OF MARRIAGE

MARRIAGE

18. NUMBER OF 19. NUMBER OF CHILDREN UNDER 18 WHOSE PHYSICAL CUSTODY WAS 20. DATE OF SEPARATION

CHILDREN UNDER 18 AWARDED TO:

IN THIS FAMILY

21. PLAINTIFF Hulbend Wile

0 HUSBAND 0 WIFE n BOTH Joint (Hulband/Wilel Other 0 No c:llildr8n

22. DIVORCE GRANTED TO 23. LEGAL GROUNDS OR CAUSE OF DIVORCE (If •nnulment • so .,.,.}

0 HUSBAND 0 WIFE 0 BOTH

24. INFORMANTS

SIGNATURE ….. OPEnnONER

0 ATTORNEY FOR PETITIONER

NAME OF INFORMANT =r:.~F

{J)Ipe CK Print)

I CERTIFY THAT A FINAL DECREE OF WAS ENTERED CONCERNING THE AE

(divon» or •nnulmentJ (Mie of dlliOI’ce or •nnulmentJ

MARRIAGE AND WAS NUMBERED …..

(CCIIXI tu. numtJer) SIGNATURE OF CLERK OF COURT OR DEPU

(SEAL) NAME OF

CLERK OR DEPUTY

{J)Ipe CK Print)