Fill and Sign the Hhs 73 Worksheet Fill Online Printable Fillable Blank Form

Worksheet 1. County/Tribal Court 2. Court Record Number 3. Husband’s Name (First, Middle, Last, Suffi x) 4a. Current Residence - Country 4b. State 4c. County 4d. City, Town or Location 4e. Residence - Street and Number 4f. Zip Code 5. Place of Birth (City and State or Foreign Country) 6. Date of Birth (Mo., Day, Yr.) Worksheet 5. Place of Birth (City and State or Foreign Country) 6. Date of Birth (Mo., Day, Yr.) Worksheet 7a. Wife’s Name (First, Middle, Last, Suffi x) 7b. Maiden Name Worksheet 7a. Wife’s Name (First, Middle, Last, Suffi x) 7b. Maiden Name Worksheet 8a. Current Residence - Country 8b. State 8c. County Worksheet 8a. Current Residence - Country 8b. State 8c. County Worksheet 8d. City, Town or Location 8e. Residence - Street and Number 8f. Zip Code Worksheet 8d. City, Town or Location 8e. Residence - Street and Number 8f. Zip Code Worksheet 9. Place of Birth (City and State or Foreign Country) 10. Date of Birth (Mo., Day, Yr.) Worksheet 9. Place of Birth (City and State or Foreign Country) 10. Date of Birth (Mo., Day, Yr.) Worksheet 11a. Place of Marriage - State 11b. County 11c. City 11d. Date of Marriage Worksheet 11a. Place of Marriage - State 11b. County 11c. City 11d. Date of Marriage Worksheet (Mo., Day, Yr.) 12a. Number of Children under 18 in this Household 12b. Number of Children Under 18 Whose Physical Custody was Awarded to: ______Husband ______Wife ______Joint Husband/Wife Number_______________________________ ______Other_________________________________________ 13. Plaintiff 14. List Former Name of Wife, if restored  Husband  Wife 15a. Attorney for Plaintiff - Name 15b. Address (Street, City or Town, State and Zip Code) 16a. I certify that the marriage of the above name persons was dissolved on 16b. Type of Decree (Mo., Day, Yr.) ______Dissolution ______Annulment 17. Clerk of the District Court or Tribal Court Making Return to the Department of Health and Human Services Finance and Support Information For Administrative Use Only. Information below will not appear on certifi ed copies of the record 18. Settlement(s) Made Alimony  Yes  No Child Support  Yes  No Property Settlement  Yes  No Medical Reimbursement  Yes  No 19. Social Security Numbers Husband:___________________________________ Wife:___________________________________ 20a. Is Husband of Hispanic or Latino Origin?  Yes  No 20b. Is Wife of Hispanic or Latina Origin?  Yes  No 21a. Husband Race 21b. Wife Check the race(s) each person considers him/herself to be  White/Caucasian   Black or African American   American Indian or Alaska Native   Asian   Native Hawaiian or Other Pacifi c Islander  WorksheetWorksheetWorksheetWorksheetWorksheet State of Nebraska Department of Health and Human Services Finance and Support Vital Records Certifi cate of Dissolution of Marriage or Annulment 2. Court Record Number Certifi cate of Dissolution of Marriage or Annulment 2. Court Record Number WORKSHEET ONLY 2. Court Record Number HHS-73 (55073) 6/06 4a. Current Residence - Country 4b. State 4c. County 4a. Current Residence - Country 4b. State 4c. County Worksheet 5. Place of Birth (City and State or Foreign Country) 6. Date of Birth (Mo., Day, Yr.) 7a. Wife’s Name (First, Middle, Last, Suffi x) 7b. Maiden Name Worksheet 7a. Wife’s Name (First, Middle, Last, Suffi x) 7b. Maiden Name Worksheet 8a. Current Residence - Country 8b. State 8c. County 11a. Place of Marriage - State 11b. County 11c. City 11d. Date of Marriage (Mo., Day, Yr.) 11a. Place of Marriage - State 11b. County 11c. City 11d. Date of Marriage (Mo., Day, Yr.) 12a. Number of Children under 18 in this Household 12b. Number of Children Under 18 Whose Physical Custody was Awarded to: ______Husband ______Wife ______Joint Husband/Wife Number_______________________________ ______Other_________________________________________ No Children Awarded Custody 13. Plaintiff 14. List Former Name of Wife, if restored 15a. Attorney for Plaintiff - Name 15b. Address (Street, City or Town, State and Zip Code) 16a. I certify that the marriage of the above name persons was dissolved on 16b. Type of Decree (Mo., Day, Yr.) ______Dissolution ______Annulment 9. Place of Birth (City and State or Foreign Country) 10. Date of Birth (Mo., Day, Yr.) WorksheetWorksheet 8a. Current Residence - Country 8b. State 8c. County WorksheetWorksheet 4d. City, Town or Location 4e. Residence - Street and Number 4f. Zip Code 4d. City, Town or Location 4e. Residence - Street and Number 4f. Zip Code 8d. City, Town or Location 8e. Residence - Street and Number 8f. Zip Code WorksheetWorksheet 8d. City, Town or Location 8e. Residence - Street and Number 8f. Zip Code WorksheetWorksheet 11a. Place of Marriage - State 11b. County 11c. City 11d. Date of Marriage (Mo., Day, Yr.) 20b. Is Wife of Hispanic or Latina Origin?