Fill and Sign the Rhode Island Department of Health Divorce Record Rhode Island Form

TYPE, OR PRINT IN PERMANENT BLACK INK BRIEF INSTRUCTIONS RHODE ISLAND DEPARTMENT OF HEALTH REPORT OF DIVORCE ON REVERSE DOCKET NUMBER       STATE FILE NUMBER       HUSBAND HUSBAND-FIRST NAME MIDDLE LAST 1a.       1b.       1c.       MAILING ADD. OF RESIDENCE-ST. OR R.F.D. AND NUMBER, CITY, TOWN , STATE, ZIP CODE CITY OR TOWN OF RESIDENCE & ST 2a.       2b.       BIRTHPLACE (STATE OR FOREIGN COUNTY) DATE OF BIRTH (Month, day, year) AGE (If D.O.B. unknown) 3.       4a.       4b.       WIFE WIFE-FIRST NAME MIDDLE LAST MAIDEN NAME 5a.       5b.       5c.       5d.       MAILING ADDRESS OF RESIDENCE-ST. OR R.F.D. AND NUM., CITY, TOWN, STATE, ZIP CODE CITY OR TOWN RESIDENCE AND STATE 6a.       6b.       BIRTHPLACE(State or Foreign Country) DATE OF BIRTH (Month, day, year) AGE (If D.O.B. unknown) 7.       8a.       8b.       PLACE OF THIS MARRIAGE-City/Town & State or Foreign Country DATE OF THIS MARRIAGE (M D Y) DATE COUPLE LAST RESIDED IN SAME HOUSEHOLD (Month, day, year) 9.       10.       11.       NUMBER OF CHILDREN UNDER 18 IN THIS HOUSEHOLD AS PETITIONER-HUSBAND, WIFE, NAME OF PETITIONER’S ATTORNEY OF THE DATE IN ITEM 11 (If none, enter a zero) BOTH, OTHER (Specify) (TYPE/PRINT) 12.       13.       14.       ATTORNEY FOR PETITIONER-ADDRESS (Street & Number or Rural Route No., City or Town, State , Zip Code LEGAL GROUNDS FOR DECREE (Specify) 15.       16.       ` DECREE DECREE GRANTED TO HUSBAND, WIFE, OTHER (Specify) COUNTY OF DECREE DATE OF FINAL DECREE (Mo., day, yr.) 17.       18.       19.       NUMBER OF CHILDREN UNDER 18 WHOSE PHYSICAL CUSTODY WAS AWARDED TO: 20. Husband       Wife       Joint (Husband/Wife)       Other       No Children COURT OFFICIAL-SIGNATURE TITLE OF COURT OFFICIAL COURT-NAME 21.       22.       23.       INFORMATION FOR STATISTICAL PURPOSES ONLY Race-Amer. Indian, Black NUMBER OF IF PREVIOUSLY MARRIED, LAST MARRIAGE ENDED EDUCATION (Specify only highest white, etc. (Specify below) MARRIAGE By Death, Divorce, grade completed.) HUSBAND First, Second, etc. Dissolution or annulment Date (month, day, year) Elem .or Secondary College (Specify below) (Specify below) (0-12) (1-4 or 5+) 24.       25.       26a.       26b.       27a       27b       RACE-Amer. Indian, Black NUMBER OF IF PREVIOUSLY MARRIED, LAST MARRIAGE ENDED EDUCATION (Specify only highest WIFE white, etc. (Specify below) MARRIAGE By Death, Divorce, grade completed.) First, Second, etc. Dissolution or annulment Date (Month, day, year) Elem .or Secondary College VS-6 (Specify below) (Specify below) (0-12) (1-4 or 5+) REV. 1-89 28.       29.       30a       30b       31a       31b       Attorney for prevailing party must complete and file this report with the final decree BRIEF INSTRUCTIONS ON REVERSE SIDE. FORM REQUIRED BY GENERAL LAWS (Section 23-3-20). The prevailing party or his or her legal representative is required by law (23-3-20) to furnish this report with the final decree to the clerk of court. INSTRUCTIONS FOR COMPLETION TYPE or PRINT in permanent black ink. Items 1 & 5 - Capitalize each letter of last name and maiden name. Enter full middle name (i.e., Robert Fulton SMITH). Items 2b & 6b - City or Town Of Residence - Refers to the city/town where the husband and the wife were living at the time the Report of Divorce form was completed. DO NOT use village names, such as Hope Valley, Saunderstown, etc., to denote city/town. Item 12 - Number of Children Under 18 In This Household As Of The Date In Item 11 (If none, enter as zero). Enter the total number of children under 18 years of age in the family at the time of the marriage dissolution, regardless of whether they were born to the divorcing couple, were children of previous marriage of either partner, or were adopted. Item 20 - Number Of Children Under 18 Whose Physical Custody Was Awarded To: Husband_____ Wife_____ Joint (Husband/Wife)____ Other____ No Children_____ The court official should enter the total number of children whose custody was awarded to each person listed. Check the box for “No Children” if there were no children under age 18 in the family. This information should be obtained from the final decree of divorce. Do not leave this item blank. For copy of handbook on Divorce Registration, contact the clerk of court or: Division of Vital Records 101 Cannon Building 75 Davis Street Providence, RI 02908-5097