Fillable FC104 (West Virginia Supreme Court of Appeals)

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FC104 (West Virginia Supreme Court of Appeals)

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BROWSE WEST VIRGINIA SUPREME COURT OF APPEALS (WV) FORMS

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SCA-FC-104: Information Requested by the Division of Vital Statistics
Review Date: 05/2014; Revision Date: 05/2014; WVSCA Approved: 06/17/2014
Page 1 of 1
IN THE FAMILY/CIRCUIT COURT OF
COUNTY, WEST VIRGINIA
INFORMATION REQUESTED BY DIVISION OF VITAL STATISTICS
[Pertaining to Divorces and Annulments]
Chapter 16, Article 5, Section 34 of
Code of West Virginia, as Amended
Civil Action Number:
Petitioner's Full Name:
Respondent's Full Name:
Petitioner's and/or Respondent's Maiden Name:
Age of Petitioner:
Age of Respondent:
Place of Marriage:
[COUNTY]
[STATE]
Date of Marriage:
/
/
Divorce: Yes No
Annulment:
Yes No
Names of Children Under 18 Years of Age Date of Birth
/
/
/ /
/ /
/ /
/ /
/ /
/ /
Date of Decree: __________________________________________________________________________________
[To be Completed by Clerk]
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FC104 (West Virginia Supreme Court of Appeals)

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Completed 25 July 2020

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