ADDITIONAL CHILDREN AFFECTED BY THIS SUIT FROM SECTION 3 (IF APPLICABLE)
CHILD 4
23a. CHILD CURRENT NAME (FIRST MIDDLE LAST SUFFIX)
23b.
DATE OF BIRTH (mm/dd/yyyy) 23c. SEX 23d. BIRTHPLACE (CITY, COUNTY AND STATE)
23e.
PRIOR NAME OF CHILD (FIRST MIDDLE LAST SUFFIX) – IF APPLICABLE
CHILD 5
24a. CHILD CURRENT NAME (FIRST MIDDLE LAST SUFFIX)
24b.
DATE OF BIRTH (mm/dd/yyyy) 24c. SEX 24d. BIRTHPLACE (CITY, COUNTY AND STATE)
24e.
PRIOR NAME OF CHILD (FIRST MIDDLE LAST SUFFIX) – IF APPLICABLE
CHILD 6
25a. CHILD CURRENT NAME (FIRST MIDDLE LAST SUFFIX)
25b.
DATE OF BIRTH (mm/dd/yyyy) 25c. SEX 25d. BIRTHPLACE (CITY, COUNTY AND STATE)
25e.
PRIOR NAME OF CHILD (FIRST MIDDLE LAST SUFFIX) – IF APPLICABLE
Instructions for Completing the Suit Affecting Parent Child Relationship Form
GENERAL REQUIREMENT:
All divorces/annulments (with or without children) and all suits affecting the parent-child relationship must be reported through the clerk of the
court to the State Vital Statistics Unit (VSU).
Consolidated rep
orting by petitioners, attorneys, and the courts is designed to make mandatory reporting more efficient, timely, and improve
the quality of reporting. However, this reporting system is only as good or timely as you make it; therefore, your attention in completing and
filing this report is critical.
Legal basis for this reporting is contained in Health and Safety Code §194.002 and Texas Family Code §§108.001-.002 and 108.004.
For information concerning reporting or questions about this form, contact field services at fieldservices@dshs.texas.gov or by phone at 512-
776-3010.
The VSU-165 form must be printed double-sided (one sheet not two).
For information on the court of continuing jurisdiction of a child, contact VSU at (888) 963-7111 ext. 2529. Inquiries should be addressed to
VSU, 1100 West 49th Street, Austin, Texas, 78756-3191; inquiries may also be faxed to (512) 776-7164 .
SECTION 1 GENERAL INF
ORMATION (REQUIRED)
This section must be completed for each report filed.
1a – d. Enter the required information to identify the court proceeding.
2. Check the type of suit being reported. This determines also which sections of the form must be completed. If more than one type of
order applies, check all that apply. Transfers from one jurisdiction to another must be reported in this section (if court number is unknown,
specify “unknown”).
3a – c. Complete the attorney information to assist in questions or follow up. If case was pro se, please enter the information of the
person completing this form.
SECTION 2 (IF APPLICABLE) REPORT OF DIVORCE OR ANNULMENT OF MARRIAGE
All divorces/annulments must be reported, even if there were no minor children. All information is required.
4-9. Rep
ort the Petitioner’s information including maiden name (if applicable ).
10-15. Report the Respondent’s information, including maiden name (if applicable ).
16. Report the number of minor children affected by this divorce; if none, record “0.” This number must correspond to the listing of
children in Section 3.
17-18. Enter the date and place of the marriage being dissolved.
SECTION 3 (IF APPLICAB
LE) CHILDREN AFFECTED BY THIS SUIT
Every child affected by the suit being reported must be listed, and all items concerning that child must be completed. If more than three children are
affected, check the “additional children listed on back of form” box, and continue to list the additional children. If more than 6 children complete
section 3 on another form, label it “continuation” and attached the continuation form to the original form.
Texas Department of State Health Services - Vital Statistics VS-165 REV 07/2017
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