IOWA DEPARTMENT OF PUBLIC HEALTH
REPORT OF DISSOLUTION
OF MARRIAGE OR ANNULMENT
114-
1. PARTY A – CURRENT NAME
FIRST MIDDLE LAST SUFFIX (if any)
2. LAST NAME PRIOR TO ANY MARRIAGE
3. STATE OF BIRTH (or foreign country)
4. DATE OF BIRTH (Month, Day, Year)
6a. RESIDENCE – STATE
6b. RESIDENCE – COUNTY
6c. RESIDENCE – CITY OR TOWN
6d. RESIDENCE – STREET ADDRESS & ZIP CODE
7. PARTY B – CURRENT NAME
8. LAST NAME PRIOR TO ANY MARRIAGE
9. STATE OF BIRTH (or foreign country)
10. DATE OF BIRTH (Month, Day, Year)
11. GENDER (Optional)
12c. RESIDENCE – CITY OR TOWN
12d. RESIDENCE – STREET ADDRESS & ZIP CODE
MARRIAGE & PETITION INFORMATION
13a. DATE OF THIS MARRIAGE
(Month, Day, Year)
13b. PLACE OF THIS MARRIAGE – STATE
(If not U.S., name of foreign country)
14. APPROX. DATE OF SEPARATION
(Month,Year)
15. NUMBER OF CHILDREN UNDER 18 IN THIS HOUSEHOLD
Number
None Party A Party B Both Other
17a. ATTORNEY FOR PETITIONER – Name (Type or Print)
17b. ATTORNEY’S MAILING ADDRESS (Street & No. or PO Box, City, State, Zip Code)
DECREE INFORMATION & CLERK OF DISTRICT COURT CERTIFICATION
– To be completed by the Clerk of District Court in the County of the Decree
Dissolution Annulment
19. NUMBER OF CHILDREN UNDER 18 WHOSE PHYSICAL CUSTODY WAS AWARED TO:
None
Party A Party B
Joint
Other
20a. DATE MARRIAGE DISSOLVED (Month, Day, Year)
20b. DATE DECREE RECORDED (Month, Day, Year)
20c. COURT FILE OR CASE NUMBER
21. SIGNATURE OF CLERK OF THE DISTRICT COURT
22. DATE SIGNED (Month, Day, Year)
CONFIDENTIAL – FOR STATISTICAL AND RESEARCH PURPOSES ONLY
23. EDUCATION – PARTY A. (Check the box
that best describes the highest degree or level of
school completed.)
8
th
grade or less
9
th
– 12
th
grade, no diploma
High school graduate or GED completed
Some college credit, but no degree
Associate degree (e.g., AA, AS)
Bachelor’s degree (e.g., BA, AB, BS)
Master’s degree
(e.g., MA, MS, MEng, Med, MSW, MBA)
Doctorate (e.g., PhD, EdD) or Professional
degree (e.g., MD, DO, DDS, DVM, LLB, JD)
Unobtainable
24. RACE – PARTY A.
(Check one or more races to indicate what Party A considers herself or himself to be.)
White
Black or African American
American Indian or Alaska Native
(Specify enrolled or principal tribe) ________________________________
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian (Specify) _________________________________
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander (Specify) ________________________________
Other (Specify) ___________________________________
Unobtainable
25. PARTY A – NUMBER OF THIS
MARRIAGE (First, Second, Third, etc.)
26. IF PARTY A PREVIOUSLY MARRIED,
HOW MANY ENDED BY DEATH OR
DISSOLUTION/ ANNULMENT?
(Do not include this marriage)
Death
Dissolution or
Annulment
27. EDUCATION – PARTY B. (Check the box
that best describes the highest degree or level of
school completed.)
8
th
grade or less
9
th
– 12
th
grade, no diploma
High school graduate or GED completed
Some college credit, but no degree
Associate degree (e.g., AA, AS)
Bachelor’s degree (e.g., BA, AB, BS)
Master’s degree
(e.g., MA, MS, MEng, Med, MSW, MBA)
Doctorate (e.g., PhD, EdD) or Professional
degree (e.g., MD, DO, DDS, DVM, LLB, JD)
Unobtainable
28. RACE – PARTY B.
(Check one or more races to indicate what Party B considers herself or himself to be.)
White
Black or African American
American Indian or Alaska Native
(Specify enrolled or principal tribe) ________________________________
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian (Specify) __________________________________
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander (Specify) __________________________________
Other (Specify) ____________________________________
Unobtainable
29. PARTY B – NUMBER OF THIS
MARRIAGE (First, Second, Third, etc.)
30. IF PARTY B PREVIOUSLY MARRIED,
HOW MANY ENDED BY DEATH OR
DISSOLUTION/ ANNULMENT?
(Do not include this marriage)
Death
Dissolution or
Annulment
Implemented by Iowa Department of Public Health effective with dissolutions or annulments occurring in Iowa January 1, 2012, and later. Version 1.4 (January 1, 2012)
