Divorce Vital Statistics {441}

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. Attorneys Address (number, street, town, State & Zip) A T T Y Petitioner (check one) Husband Wife Both Other (specify) 1. Husband's Name (First ­ Middle ­ Last) 3a. Residence (Number and Street) 3d. State 3e. Zip Code Name of Petitioner's Attorney 2. SSN 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 11. Wife's Last Name Prior to First Marriage 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 3c. County 5. Date of Birth (mm/dd/yyyy) 8. Number of this marriage 1st, 2nd, etc. (specify below) H U S B A N D 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. Wife's Name (First ­ Middle ­ Last) 13a. Residence (Number and Street) 13d. State 13e. Zip Code 9. If previously married: Date of your last previous marriage (Month, Day, Year) 9b. Preceding marriage ended by (check one) Death Divorce Annulment 9c. Date preceding marriage ended (Month, Day, Year) 12. SSN 13c. County 15. Date of Birth (mm/dd/yyyy) 18. Number of this marriage 1st, 2nd, etc. (specify below) W I F E 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) 19. If previously married: Date of your last previous marriage (Month, Day, Year) 19b. Preceding marriage ended by (check one) Death Divorce Annulment 19c. Date preceding marriage ended (Month, Day, Year) M A R R I A G E D E C R E E 20. Date of this marriage (Month, Day, Year) 22. Date couple last resided in same household 21a. Place where this marriage 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: Husband Wife Joint (Husband/Wife) Other No Children No Yes CONTESTED? 24. I certify that the marriage of the named persons was dissolved on (MM/DD/YYYY) 28. Title of Court ********** FOR OFFICIAL USE ONLY ********** 25. Type of Decree (check one) 26. County of Decree (check one) Divorce Annulment 29. Signature of Certifying Official New Castle Kent Sussex 30. Title of Certifying Official CLERK OF COURT 27. Date Recorded (MM/DD/YYYY) 31. Date Signed (MM/DD/YYYY) 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