LEERS DIVORCE WORKSHEET

COURT FILE NUMBER: STATE FILE NUMBER:

HUSBAND’S NAME - LAST FIRST MIDDLE SUFFIX DATE OF BIRTH

HUSBAND
(MM / DD / YY)

SOCIAL SECURITY NUMBER:

PLACE OF BIRTH COUNTRY STATE/ TERRITORY/ PROVINCE CITY

RESIDENCE COUNTRY STREET ADDRESS APT. NO.

STATE

PARISH/COUNTY CITY, TOWN, OR LOCATION ZIP CODE

WIFE’S NAME - LAST FIRST MIDDLE SUFFIX DATE OF BIRTH

W I F E
(MM / DD / YY)

SOCIAL SECURITY NUMBER:

PLACE OF BIRTH COUNTRY STATE/ TERRITORY/ PROVINCE CITY

RESIDENCE COUNTRY STREET ADDRESS APT. NO.

STATE

PARISH/COUNTY CITY, TOWN, OR LOCATION ZIP CODE

PLACE OF THIS COUNTRY STATE/ TERRITORY/ PROVINCE COUNTY CITY

MARRIAGE MARRIAGE

DATE OF THIS MARRIAGE DATE OF LAST RESIDENCE IN THE NUMBER OF CHILDREN UNDER 18 IN THE PETITIONER
(MM / DD / YY) SAME HOUSE (MM / DD / YY) HOUSEHOLD AS OF LAST DATE OF RESIDENCE □ HUSBAND □ WIFE
□ NUMBER □ NONE □ BOTH □ OTHER

PETITIONER’S ATTORNEY NAME - LAST FIRST MIDDLE SUFFIX

L E G A L

ADDRESS COUNTRY STATE/ TERRITORY/ PROVINCE COUNTY CITY BAR ROLL NUMBER
ATTORNEY

DECREE GRANTED TO DATE OF DECREE DATE RECORDED TYPE OF DECREE

D E C R E E
□ HUSBAND □ WIFE (MM / DD / YY) (MM / DD / YY) □ DIVORCE
□ BOTH □ OTHER □ DISSOLUTION OF MARRIAGE
□ ANNULMENT (SPECIFY)

NUMBER OF CHILDREN UNDER 18 WHOSE PHYSICAL CUSTODY WAS AWARDED TO:

□ HUSBAND □ WIFE □ BOTH □ OTHER (SPECIFY) ______________________________ □ NO CHILDREN

PARISH OF DECREE FACILITY TITLE OF COURT I CERTIFY THAT THE MARRIAGE OF THE ABOVE NAMED
PERSONS WAS DISSOLVED ON (MONTH, DAY, YEAR)

CERTIFIER TITLE CERTIFIER NAME SIGNATURE OF CERTIFYING OFFICIAL DATE CERTIFIED

ASSIGNMENT
□ CLERK OF COURT (MM / DD / YY)
□ DEPUTY CLERK OF COURT
□ OTHER

ADDRESS OF COUNTRY STREET ADDRESS APT. NO. DATE FILED BY STATE REGISTRAR
CERTIFIER (MM / DD / YY)
STATE CITY, TOWN, OR LOCATION ZIP CODE

CONFIDENTIAL THE INFORMATION BELOW WILL NOT APPEAR ON CERTIFIED COPIES OF THE RECORD

HUSBAND’S EDUCATION (Check the HUSBAND’S RACE (Check one or more races to
HUSBAND – NUMBER OF THIS MARRIAGE box that best describes the highest indicate what race the mother considers herself
HUSBAND degree or level of school completed at
to be)
□ White
the time of delivery)
□ Black or African American
□ 8th grade or less □ American Indian or Alaska Native
IF PREVIOUSLY MARRIED REASON LAST
MARRIAGE ENDED (Name of the enrolled or principal tribe)
□ 9th - 12th grade, no diploma _______________________________
□ High school graduate or GED □ Asian Indian
□ DEATH
completed □ Chinese
□ DIVORCE
□ Filipino
□ DISSOLUTION OF MARRIAGE □ Some college credit but no degree
□ Japanese
□ ANNULMENT (SPECIFY)
□ Associate degree (e.g., AA, AS) □ Korean
□ Vietnamese
□ Bachelor’s degree (e.g., BA, AB, BS)
□ Other Asian (Specify) _____________________
DATED ENDED (MM / DD / YY)
□ Master’s degree (e.g., MA, MS, □ Native Hawaiian
MEng, MEd, MSW, MBA) □ Guamanian or Chamorro
□ Samoan
□ Doctorate (e.g., PhD, EdD) or
Professional degree (e.g., MD, DDS, □ Other Pacific Islander (Specify) ______________
DVM, LLB, JD) □ Other (Specify) ___________________________

WIFE’S EDUCATION (Check the WIFE’’S RACE (Check one or more races to indicate
WIFE – NUMBER OF THIS MARRIAGE box that best describes the highest what race the mother considers herself to be)
W I F E degree or level of school completed at □ White
the time of delivery) □ Black or African American
□ American Indian or Alaska Native
IF PREVIOUSLY MARRIED REASON LAST □ 8th grade or less
(Name of the enrolled or principal tribe)
MARRIAGE ENDED _______________________________
□ 9th - 12th grade, no diploma
□ Asian Indian
□ DEATH □ High school graduate or GED □ Chinese
completed
□ DIVORCE □ Filipino
□ DISSOLUTION OF MARRIAGE □ Some college credit but no degree □ Japanese
□ ANNULMENT (SPECIFY) □ Korean
□ Associate degree (e.g., AA, AS) □ Vietnamese
□ Bachelor’s degree (e.g., BA, AB, BS) □ Other Asian (Specify) _____________________
DATED ENDED (MM / DD / YY) □ Native Hawaiian
□ Master’s degree (e.g., MA, MS, □ Guamanian or Chamorro
MEng, MEd, MSW, MBA)
□ Samoan
□ Doctorate (e.g., PhD, EdD) or □ Other Pacific Islander (Specify) _____________
Professional degree (e.g., MD, DDS, □ Other (Specify) __________________________
DVM, LLB, JD)