Form R-408 rev4 12/2014 draft
THE COMMONWEALTH OF MASSACHUSETTS
Registry of Vital Records and Statistics
NOT A PUBLIC RECORD
Name of Court/County:
Docket Number:
TYPE OF JUDGMENT:
Absolute Divorce
Annulment
Date of this Marriage:
State/Country of Marriage:
Date of Judgment:
Date of Absolute Divorce:
Cause for which divorce or annulment was granted:
PARTY A
Plaintiff
Defendant
1a. Full Name:
First
Middle
Last
1b.
Surname upon Divorce/Annulment
1c.
Surname at birth or adoption
2. Date of Birth
3. Sex:
M F
4. SSN
5. Number of this
Marriage (1
st
, 2
nd
):
6. Number of Minor
Children in Custody of
Party A:
7a. Current Residence:
# and Street (not a mailing address):
7b. City/Town
7c. State/Country
7d. Zip Code
PARTY B
Plaintiff
Defendant
8a. Full Name:
First
Middle
Last
8b.
Surname upon Divorce/Annulment
8c.
Surname at birth or adoption
9. Date of Birth
10. Sex:
M F
11. SSN
12. Number of
this Marriage (1
st
,
2
nd
):
13. Number of Minor
Children in Custody of
Party B:
14a. Current Residence:
# and Street (not a mailing address):
14b. City/Town
14c. State/Country
14d. Zip Code
CHILDREN OF THIS MARRIAGE
15. Total #
List full names
and dates of
birth.
Continue on
r
everse if
necessary.
16. Names: First Middle Last
17. Date(s) of Birth
a.
a.
b.
b.
c.
c.
d.
d.
e.
e.
RVRS USE ONLY
Form R-408 rev4 041207 draft (reverse)
Completing this Form
STATUTORY AUTHORITY
This report is required by G.L. c. 208 §6(b) and 46, and G.L. c.111 §2 for the creation of a statewide index, for
approved statistical and research purposes, and for use by state or federal agencies as allowed by law. This
form is not a public record.
Chapter 4: Section 6. Rules for construction of statutes
In construing statutes the following rules shall be observed, unless their observance would involve a construction inconsistent with the
manifest intent of the law-making body or repugnant to the context of the same statute: ...
Fourth, ... words of one gender may be construed to include the other gender and the neuter.
Chapter 111: Section 2. Duties of commissioner of public health
The commissioner shall prepare from the birth, marriage and death records received by him under the provisions of chapter forty-six, and
from the divorce returns received by him under the provisions of section forty-six of chapter two hundred and eight, such statistical tables as
he deems useful, and shall make annual report thereof to the general court. The commissioner may transmit such information to the
appropriate agency of the federal government to participate in the development of a cooperative system for producing uniform statistical
information at the federal, state and local level. The commissioner may make further use of such records as he deems useful for
administrative and research purposes connected with health programs and population studies. He shall, as soon as is reasonably practicable,
cause the birth, marriage and death records to be bound with indexes thereto and shall retain their custody. He shall prepare an alphabetical
index of such divorce returns showing the names of the parties, year and number of the judgment and the county in which the divorce
occurred.
Chapter 208: Section 6b. Filing of action; statistical report
An action for divorce shall be commenced in probate court by the filing of a complaint. Said complaint shall be accompanied by a statistical
report, upon a form prepared by the commissioner of public health and made available through the office of the register of probate, to include
the name, residence, date of birth and social security number of each of the parties, the name of the plaintiff, the number of times each of the
parties had been married before, if any, the date of the marriage being dissolved, the number of children born of such marriage, if any, the
name and date of birth of each such child, the number of minor children in the care and custody of the parties, if any, and such additional
information as the commissioner of public health deems useful for statistical and research purposes. The state registrar may make such
information available to the IV-D agency as set forth in chapter 119A [MDOR CSE] and such other state or federal agencies as may be
required by law.
Chapter 208: Section 23. Resumption of former name by woman
The court granting a divorce may allow a woman to resume her maiden name or that of a former husband.
Chapter 208: Section 46. Statistical reports; additional information
The registers of probate shall receive the statistical reports filed pursuant to section six B; and shall, upon a divorce becoming absolute, add
to the information contained therein the date and number of the judgment, the cause for which the divorce was granted, and such additional
information as the commissioner of public health deems useful for statistical and research purposes and shall further, on the tenth day of the
month following every month in which divorces become absolute, transmit such reports to the commissioner of public health. Any such
information forwarded to the commissioner of public health shall not constitute a public record nor be available except as may be necessary
for the purposes stated in section two of chapter one hundred and eleven.
INSTRUCTIONS FOR COMPLETION AND TRANSMISSION
Complete all relevant items at the time of complaint; add information about date and number of judgment and cause at
the time the divorce becomes final. If this form is not completed properly, it will be returned to you for correction.
Please type or write neatly. This information will be entered into an electronic index.
Do not leave fields blank. If the field cannot be completed (e.g., the number of prior marriages is unknown and cannot be
determined) then place dashes (“---“) in the field to indicate that it is deliberately left blank.
Submit forms on or before the tenth day of the month following every month in which divorces become absolute.
Mail this form to:
Registry of Vital Records and Statistics, Statistics Unit
150 Mount Vernon St., 1
st
Floor
Dorchester, MA 02125-3105
List any additional children of this marriage, or other relevant information here: