Fill and Sign the Rev 0412 Form

Form 441(Rev 04/12) CERTIFICATE OF DIVORCE OR ANNULMENT State of Delaware DIVISION OF PUBLIC HEALTH OFFICE OF VITAL STATISTICS STATE FILE COPY HEALTH STATISTICS COPY FAMILY COURT COPY State File No. Petitioner (check one)Name of Petitioner’s AttorneyAttorneys Address (number, street, town, State & Zip) Husband Wife BothA T T Y Other (specify) 1. Husband’s Name (First – Middle – Last) 2. SSN 3a. Residence (Number and Street)3b. City3c. County 3d. State3e. Zip Code4. Birthplace (State or Foreign Country)5. Date of Birth (mm/dd/yyyy) 8. Number of this marriage 1st , 2nd , etc. (specify below) 6. Race (Check which race you consider yourself to be.) White Black or African American American Indian or Alaska Native(Name of principal tribe) 6b. Hispanic Origin (Check box with Selection) No, not Spanish/Hispanic/Latina Yes, Mexican, Mexican American, Chicana Yes, Puerto Rican Yes, Cuban Yes, Other Spanish/Hispanic/Latina9. If previously married: Date of your last previous marriage (Month, Day, Year) (specify) Asian Indian Chinese Filipino Japanese Korean Vietnamese Other Asian (specify) 9b. Preceding marriage ended by (check one) Death Divorce Annulment Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander (specify) H U SBA N D Other (specify) 7. Education (check one) 8th grade or less 9th -12th grade, but no diploma High school graduate or GED completed Some college credit, but no degree Associate degree Bachelor’s degree Master’s degree Doctorate or professional degree9c. Date preceding marriage ended (Month, Day, Year) 10. Wife’s Name (First – Middle – Last) 11. Wife’s Last Name Prior to First Marriage12. SSN 13a. Residence (Number and Street)13b. City13c. County 13d. State13e. Zip Code14. Birthplace (State or Foreign Country)15. Date of Birth (mm/dd/yyyy) 18. Number of this marriage 1st , 2nd , etc. (specify below) 16. Race (Check which race you consider yourself to be.) White Black or African American American Indian or Alaska Native(Name of principal tribe) 16b. Hispanic Origin (Check box with Selection) No, not Spanish/Hispanic/Latina Yes, Mexican, Mexican American, Chicana Yes, Puerto Rican Yes, Cuban Yes, Other Spanish/Hispanic/Latina19. If previously married: Date of your last previous marriage (Month, Day, Year) (specify) Asian Indian Chinese Filipino Japanese Korean Vietnamese19b. Preceding marriage ended by (check one) Death Divorce Annulment Other Asian (specify) Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander (specify) W I F E Other (specify) 17. Education (check one) 8th grade or less 9th -12th grade, but no diploma High school graduate or GED completed Some college credit, but no degree Associate degree Bachelor’s degree Master’s degree Doctorate or professional degree19c. Date preceding marriage ended (Month, Day, Year) 20. Date of this marriage (Month, Day, Year)21a. Place where this marriage took place (city, 21b. County21c. State or Foreign Country Town or Location) 22. Date couple last resided in same household23. Number of children under 18 in this household as of date in item 2223b. Number of children whose physical custody was awarded to:Husband DDWife DDJoint (Husband/Wife) DDOther No ChildrenMARRIAGE CONTESTED? No Yes ********** FOR OFFICIAL USE ONLY ********** 24. I certify that the marriage of the named persons was dissolved on (MM/DD/YYYY)25. Type of Decree (check one)26. County of Decree(check one)27. Date Recorded(MM/DD/YYYY) Divorce Annulment New Castle Kent Sussex 28. Title of Court29. Signature of Certifying Official30. Title of Certifying Official31. Date Signed (MM/DD/YYYY)DECR EE CLERK OF COURT ATTORNEY – Complete items 1-23b when filing petition and leave with Clerk of the CourtCLERK OF COURT – After final decree, complete items 24-31 and forward to: Office of Vital Statistics, 417 Federal Street, Dover, DE 19901