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)
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