February 16
Previous Marriage Information Sheet
This sheet must be filled out and submitted with the DS-11 application for name change(s)
that occurred from of a previous marriage.
Applicant’s Information
Your Name: _____________________________________________________________________
First Middle Last
Your Date of Birth: _______/________/______________
mm dd yyyy
Ex-Spouse’s Information
Full Name: ______________________________________________________________________
First Middle Last
Date of Birth: _______/________/______________
mm dd yyyy
Place of Birth: _____________________________________________________
State or foreign country
U. S. Citizen? Yes No
Prior Marriage Information
Date of Prior Marriage: _______/________/______________
mm dd yyyy
Date of Termination of Marriage: _______/________/______________
mm dd yyyy
Reason for Termination: Death