NOTE:
ITEMS 1-24 ON THIS
FORM TO BE
COMPlETED BY
PETITIONER OR
ATIORNEY AND FilED
WITH ClERK OFCOURT
WITH PETITION OR
DECREE
COMMONWEALTH OF VIRGINIA - REPORT OF DIVORCE OR ANNULMENT
Department of Health - Division of Vital Records - Richmond
1 CIRCUIT COURT FOR CITY OR COUNTY OF
African American
5. RACE
8. USUAl
RESIDENCE
9. FUll MAIDEN
NAME
(slale or foreign country)
113. NUMBER OF
{first, second, etc.)
THIS MARRIAGE
First
(county)
1
12
College
( 1-4 or 5+)
I
2
{stole)
(county- if not independent city)
D HUSBAND D WIFE D BOTH
17. DATE OF
MARRIAGE
(state or foreign country)
11/11/2000
20. DATE OF SEPARATION
19. NUMBER OF CHilDREN UNDER 18 IN THIS FAMilY WHOSE PHYSICAl
CUSTODY WAS AWARDED TO:
Husband
D HUSBAND D WIFED BOTH
08/08/2008
Wife
Joint (Husband/Wife)
0No Children
Other
23. lEGAl GROUND OR CAUSE OF DIVORCE
{if annulment- so state)
Separation without cohabitation for period in excess of one year
DPETITIONER
0ATIORNEY FOR PETITIONER
~
Andrew Attorney, Attorney at Law
CONCERNING THE ABOVE
(date of divorce or annulmen~
{divorce or onnulmen~
~
MARRIAGE AND WAS NUMBERED
(court life number)
(SEAL)
PO Box XXX, Anytown, VA 22038
ADDRESS OF
INFORMANT
WAS ENTERED
I CERTIFY THAT A FINAl DECREE OF
VS4 7.04
{state)
01/01/1980
14. EDUCATION ElementartJ.or Secondary
(Specify only highest
( 12)
grode completed)
{city or town}
(street no. or rural route number}
22. DIVORCE GRANTED TO
SECTION 32.1-268
CODE OF VIRGINIA
3
2200 Wife Street, Anytown, VA, Fairfax Co.,Virginia XXXXX
21. PlAINTIFF
NAME OF
INFORMANT
{Type or Print)
(county- if not independent city}
11 DATE OF
BIRTH
or town)
Annandale,(cityFairfax
County, Virginia
18. NUMBER OF
CHilDREN UNDER 18
IN THIS FAMilY
College
(1-4 or5+)
I
I 9A XXX-XX-XXXX
SOCIAl SECURITY NUMBER
Massachusetts
Caucasian
24. INFORMANT'S
SIGNATURE
12
7. EDUCATION Elementary or Secondary
(Specify only highest
(Q./2)
grade completed)
{city or town}
(street no. or rural route number}
15. USUAl
RESIDENCE
ClERK OF COURT Will
CERTIFY AND FORWARD
TO STATE REGISTRAR BY
1OTH DAY OF MONTH
FOllOWING DATE FINAl
DECREE IS GRANTED
Second
{first, second, etc.)
,6. NUMBER OF
THIS MARRIAGE
2000 Husband Street, Anytown, Fairfax Co., Virginia 22XXX
12. RACE
16. PlACE OF
MARRIAGE
01/01/1980
4. DATE OF
BIRTH
Jane Susan Doe
10. PlACE OF
BIRTH
WIFE
I 2A XXX-XX-XXXX
SOCIAl SECURITY NUMBER
Washington,
DC country)
(state or foreign
3. PlACE OF
BIRTH
PlEASE PREPARE BY
TYPEWRITER OR PRINT
IN BlACK UNFADING INK
THIS IS A PERMANENT
RECORD
I STATE
FilE
NUMBER
Johnny Joe Smith
2. FUll
NAME
HUSBAND
Fairfax County
SIGNATURE OF ClERK OF COURT OR DEPUTY
NAME OF
ClERK OR DEPUTY
{Type or Print)