TYPE IN PERMANENT
DARK INK
ADPH- HS-16 / Rev. 04-06-20
CIRCUIT CLERK MUST MAIL THIS REPORT BY THE FIFTH (5TH) OF EACH MONTH TO: CENTER FOR HEALTH STATISTICS, P.O. BOX 5618, MONTGOMERY, AL 36103 - 5618
17. USUAL RESIDENCE - STATE 18. COUNTY
21. NUMBER OF THIS MARRIAGE (First, Second, etc.)
22. Give the total number of children for whom custody was determined and indicate the number awarded to each party.
Enter a “0” for the total if the custody of no children under 18 was subject to this action.
___ Spouse 1 ____Joint
_____ Spouse 2 _____Other ____Total Children/Custody was Determined
25. PLACE OF THIS MARRIAGE (City, County, State)
28. PETITIONER’S ATTORNEY OR REPRESENTATIVE (Type)
30. TYPE OF DECREE (Specify Divorce, Annulment, etc.) 31. DATE OF FINAL DECREE (Month, Day, Year) 32. DECREE AWARDED TO
o Spouse 1 o Spouse 2 o Both
33. TITLE OF COURT
CIRCUIT
34. LEGAL GROUNDS FOR DECREE
29. ADDRESS (Street and Number or RFD Number, City, State, Zip Code)
35. SIGNATURE OF OFFICIAL 36. TITLE OF OFFICIAL 37. TRIAL DOCKET NUMBER
26. DATE OF THIS MARRIAGE (Month, Day, Year) 27. PETITIONER
o Spouse 1 o Spouse 2 o Both o Other, Specify______________
24. DATE COUPLE SEPARATED (Month, Day, Year)
23. NUMBER OF CHILDREN UNDER 18 IN THIS HOUSEHOLD
AS OF THE DATE IN ITEM 24 (Enter “0” if no children)
14. DATE OF BIRTH (Month, Day, Year)
4. DATE OF BIRTH (Month, Day, Year)
15. SEX (Male or Female)
5. SEX (Male or Female)
19. CITY - TOWN OR LOCATION
16. RACE (Specify American Indian, Black, White, etc.)
6. RACE (Specify American Indian, Black, White, etc.)
20. ADDRESS – Street and Number or RFD Number Zip Code
Petitioner’s Representative must file this form with the Circuit Court at the time the petition is filed.
2. SPOUSE 1 NAME First Middle Last (Print last name all capitals) Suix (Sr, Jr, etc.)
11. NUMBER OF THIS MARRIAGE (First, Second, etc.)
12. SPOUSE 2 NAME First Middle Last (Print last name all capitals) Suix (Sr, Jr, etc.)
13. LAST NAME PRIOR TO FIRST MARRIAGE
3. LAST NAME PRIOR TO FIRST MARRIAGE
10. ADDRESS - Street and Number or RFD Number Zip Code
7. USUAL RESIDENCE - STATE 8. COUNTY 9. CITY - TOWN OR LOCATION
1. COUNTY OF DECREE
ALABAMA
CERTIFICATE OF DIVORCE
State File Number
101
DECREE
OFFICIAL
38. SPOUSE 1 SOCIAL SECURITY NUMBER
40. SPOUSE 2 SOCIAL SECURITY NUMBER
MARRIAGE
SPOUSE 2
SPOUSE 1
39. EDUCATION (Specify ONLY highest grade completed)
41. EDUCATION (Specify ONLY highest grade completed)
College (1 - 4 or 5+)Elementary or High School (0 - 12)
College (1 - 4 or 5+)Elementary or High School (0 - 12)
INFORMATION BELOW WILL NOT APPEAR ON CERTIFIED COPIES
