Civil Union Vital Statistics {441CU}

Form 441CU (Rev 04/12) CERTIFICATE OF DIVORCE OR ANNULMENT OF CIVIL UNION State of Delaware DIVISION OF PUBLIC HEALTH OFFICE OF VITAL STATISTICS STATE FILE COPY Petitioner (check one) Party A Party B Both Other (specify) 1. Party A's Full Name (First ­ Middle ­ Last) 3a. Residence (Number and Street) 3d. State 3e. Zip Code 3b. City 4. Birthplace (State or Foreign Country) 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/Latina (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 degree HEALTH STATISTICS COPY FAMILY COURT COPY State File No. Attorneys Address (number, street, town, State & Zip) Name of Petitioner's Attorney 2. SSN 3c. County 5. Date of Birth (mm/dd/yyyy) 8. Number of this marriage or civil union 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) Asian Indian Chinese Filipino Japanese Korean Vietnamese Other Asian (specify) Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander (specify) Other (specify) 10. Party B's Full Name (First ­ Middle ­ Last) 13a. Residence (Number and Street) 13d. State 13e. Zip Code 9. If previously married or civil union: Date of your last previous marriage or civil union (Month, Day, Year) 9b. Preceding marriage or civil union ended by (check one) Death Divorce Annulment Dissolution 9c. Date preceding marriage or civil union Ended (Month, Day, Year) 12. SSN 13c. County 15. Date of Birth (mm/dd/yyyy) 18. Number of this marriage or civil union 1st, 2nd, etc. (specify below) 19. If previously married or civil union: Date of your last previous marriage or civil union (Month, Day, Year) 19b. Preceding marriage or civil union ended by (check one) Death Divorce Annulment Dissolution 19c. Date preceding marriage or civil union ended (Month, Day, Year) 11. Party B's Last Name Prior to First Marriage or civil union 13b. City 14. Birthplace (State or Foreign Country) 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/Latina (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 degree 16. Race (Check which race you consider yourself to be.) White Black or African American American Indian or Alaska Native (Name of principal tribe) Asian Indian Chinese Filipino Japanese Korean Vietnamese Other Asian (specify) Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander (specify) Other (specify) 20. Date of this civil union (Month, Day, Year) 22. Date couple last resided in same household 21a. Place where this civil union took place (city, Town or Location) 23. Number of children under 18 in this household as of date in item 22 21b. County 21c. State or Foreign Country 23b. Number of children whose physical custody was awarded to: Party A Party B Joint (Party A/Party B) Other No Children No Yes CONTESTED? 27. Date Recorded (MM/DD/YYYY) 31. Date Signed (MM/DD/YYYY) 24. I certify that the civil union of the named persons was dissolved on (MM/DD/YYYY) 28. Title of Court 25. Type of Decree (check one) Divorce Annulment 29. Signature of Certifying Official 26. County of Decree (check one) New Castle Kent Sussex 30. Title of Certifying Official CLERK OF COURT ATTORNEY ­ Complete items 1-23b when filing petition and leave with Clerk of the Court CLERK OF COURT ­ After final decree, complete items 24-31 and forward to: Office of Vital Statistics, 417 Federal Street, Dover, DE 19901 American LegalNet, Inc. www.FormsWorkFlow.com