__________________________________
State File Number
RECORD OF
DIVORCE OR ANNULMENT
MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
By authority of MCL 333.2813.
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Court Case Number
_________________________________
County
1. Plaintiff’s Full Name _______________________________________________________ 2. |
Plaintiff’s Birthdate ______________ |
□ |
Male |
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Female |
(First, Middle, Last) |
(Month, Day, Year) |
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3.Last Name Before First Married (if different) _____________________________________________________________________
4.Plaintiff’s Residence _______________________________________________________________________________________
(City, Village, or Township)(County)(State)
5. |
Plaintiff’s Birthplace ______________________________________________________ 6. Number of this Marriage __________ |
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(State or Foreign Country) |
(First, Second, etc. - Specify) |
7. |
Defendant’s Full Name ____________________________________________________ 8. Defendant’s Birthdate ____________ |
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□ |
Male |
□ |
Female |
(First, Middle, Last) |
(Month, Day, Year) |
9.Last Name Before First Married (if different) _____________________________________________________________________
10.Defendant’s Residence _____________________________________________________________________________________
(City, Village, or Township)(County)(State)
11. Defendant’s Birthplace ___________________________________________________ 12. Number of this Marriage __________
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(State or Foreign Country) |
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(First, Second, etc. - Specify) |
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13. |
Place of this Marriage ______________________________________________________________________________________ |
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(City, Village, or Township) |
(County) |
□ |
(State or Foreign Country) |
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14. |
Date of this Marriage _____________________ |
15. Date Couple Last Resided |
Check if Not |
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Separated |
______________ |
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in Same Household |
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(Month, Day, Year) |
□ |
(Month, Day, Year) |
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Check If |
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16. |
Number of Minor Children in Household at Separation Date (Filing Date if Not Separated) |
None |
______________ |
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(Number) |
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17. |
Plaintiff’s Attorney _________________________________________________________________________________________ |
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(Name - Type or Print) |
(Bar Number) |
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18. |
Attorney’s Address _________________________________________________________________________________________ |
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(Number and Street) |
(City) |
(State) |
(Zip Code) |
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20. Number of Minor Children Whose |
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19. |
Judgment of ____________________ Physical Custody was Awarded to: Plaintiff____ Defendant____ Joint____ Other____ |
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(Divorce/Annulment - Specify) |
(Number) |
(Number) |
(Number) |
(Number) |
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□ No Children |
□ Unknown |
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21. |
Judgment Recorded on _______________________ 22. I certify that this Divorce was granted on ________________________ |
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(Month, Day, Year) |
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(Month, Day, Year) |
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23. |
Certifying Oficial _________________________________________________________________________________________ |
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(Signature) |
(Title) |
(Date Signed) |
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Failure to provide the required information is a misdemeanor punishable by imprisonment
of not more than 1 year or a ine of not more than $1,000.00 or both.
DCH-0838 (Rev. 08/2015)