Vital Statistics Form {VS-14a}

State of New Hampshire CASE NUMBER Certificate Of Divorce, Civil Union (CU) Dissolution Legal Separation Or Annulment STATE FILE NUMBER This form must be word processed or typewritten. The following information will be completed by the petitioner as indicated or by one of the joint petitioners and filed with the court prior to the hearing on the merits in accordance with court rules. 1.b. Suffix. 1c. Last name & suffix before 1st marriage or CU Last (Current) PERSON A 1a. Person A's name ­ First Middle (if applicable) 2. Person A's gender Male Female 4. Birthplace (State or Foreign Country) 3a. Residence ­ City, town or location (at time of filing) 5. Date of birth (MM/DD/YYYY) 3b. County 3c. State 6. Number of this marriage or CU (Specify first, second, etc.) 7. Social security number 8. If previously joined in marriage or civil union, how many ended by: (do not include current marriage or civil union) 9. Education: (specify highest grade completed) Elementary or secondary (0-12) Death Number Civil Union Dissolution Divorce/Annulment Number Last (Current) Number College (1-4 or 5+) PERSON B 10a. Person B's name ­ First Middle 10.b. Suffix 10c. Last name & suffix before 1st marriage or CU (if applicable) 11. Person B's gender Male Female 13. Birthplace (State or Foreign Country) 12a. Residence ­ City, town or location (at time of filing) 14. Date of birth (MM/DD/YYYY) 12b. County 12c. State 15. Number of this marriage or CU (Specify first, second, etc.) 16. Social security number 17. If previously joined in marriage or civil union, how many ended by: (do not include current marriage or civil union) 18. Education: (specify highest grade completed) Elementary or secondary (0-12) Death Number Civil Union Dissolution Divorce/Annulment Number Number College (1-4 or 5+) MARRIAGE / 19. Place of this marriage or civil union CIVIL UNION (City/Town ) 19b. County 19c. State (or foreign country) 20. Date of this marriage or CU (MM/DD/YYYY) 21. Date couple last resided in same household (MM/DD/YYYY) ATTORNEY 23a. Name of person completing form: 22a. Number of children born alive or 22b. Number of children under age 18 in adopted during this marriage/civil union this household as of date in Item 21 23b. Address attorney self represented 23c. Date (this form was completed) (MM/DD/YYYY) attorney self represented (Street and Number, City/Town, State, Zip Code) BELOW THIS LINE TO BE COMPLETED BY THE COURT 24b. Cause for filing 24c. A decree was entered: There was an: 24a. Date petition filed with court Irreconcilable differences Uncontested hearing (MM/DD/YYYY) Other (specify) Contested hearing Defaulted hearing DECREE 25b. Date decree becomes final: (MM/DD/YYYY) 26a. Name of hearing official: (first and last name) 28. Decision making responsibility for child/children shall be with: Both Parents Person A Person B Other (specify) Not applicable 25a. Type of decree Divorce Legal separation Annulment CU Dissolution 26b. Official capacity: Judge Marital Master 30. Residential responsibility was: Uncontested Contested Defaulted Not applicable 27a. Name to be used by Person A after divorce: Same as present (1a & b) Name prior to 1st marriage or CU (1c) Other (specify) 29a. Number of children under age 18 for whom residential responsibility is with: Both Parents # Person A # Person B # Other (specify) # Not applicable 27b. Name to be used by Person B after divorce: Same as present (10a & b) Name prior to 1st marriage or CU (10c) Other (specify) 31. Petitioner: Person A Person B Joint Other (specify) 32a. Signature of court official: I certify that the above is correct to 32b. Court name: the best of my knowledge. 32c. Date signed: (MM/DD/YYYY) SOS/DVRA VS 14A Rev 12/2010 American LegalNet, Inc. www.FormsWorkFlow.com