Virginia VS-4 Statistical Reporting form

The VS-4 Statistical Reporting Form is a form used to transfer the information related to the divorce to the department of health in the State of Virginia.

Extracted Text for Proper Search

NOTE: ITEMS 	1·24 	ON 	THIS 	FORM 	TO 	BE 	COMPLETED 	BY 	PETITIONER 	OR 	ATTORNEY 	AND 	FILED 	Wl1l4 	CLERK 	OF 	COURT 	WITH 	PETITION 	OR 	DECREE 
PLEASE 	PREPARE 	BY 	TYPEWRITER 	OR 	PRINT 	IN BLACK 	UNFADING 	INK 	THIS 	IS A PERMANENT 	RECORD. 
CLERK 	OF 	COURT 	WILL 	CERTIFY 	AND 	FORWARD 	TO 	STATE 	REGISTRAR 	BY 	10TH 	DAY 	OF 	MONTH 	FOLLOWING 	DATE 	FINAL 	DECREE 	IS GRANTED. 	
SECTION 	32.1·281 	CODE 	OF 	VIRGINIA 	
APPENDIXM 	
COMMONWEALTH 	OF 	VIRGINIA-	REPORT 	OF 	DIVORCE OR 	ANNULMENT 	
Department 	of 	Health 	-Division 	of 	VItal Recorda 	-Richmond 	
1. CIRCUIT 	COURT 	FOR 	CITY 	OR 	COUNTY 	OF 	I STATEFILE NUMBER 	
2. FULL 	~2A. 	SOCIAL 	SECURITY 	I 	NAME 	
3. PI.ACEOF 	(,.,. 	CK tot./gtl 	ctNI'IIIy) 	4. 	DATE 	OF 	BIRTH 	BIRTH 	
5. RACE 	I 6. NUMBER 	OF 	(flm, 	-.d. 	etc.) 	7. 	EDUCATION 	a.n-tary 	CK s-Jdary 	I 	(1~ 	HUSBAND 	THIS 	MARRIAGE 	(Sprlcify 	only 	ltig/IHI  (0-12} 	I 	~~) 	I 	
8. USUAL 	(.net 	no. 	or rulal 	tt:IIM 	no.) 	(city 	CK town) 	(=unty-H 	not 	• ..,..,., 	city) 	(,.,.) 	RESIDENCE 	
9. FULL 	MAIDEN 	.. 	19A. 	SOCIAL 	SECURITY 	I 	NAME 	
10. 	PlACE 	OF 	( .. te CK ltWign 	ctNI'IIIy) 	11. 	DATE 	OF 	BIRTH 
BIRTH 	
12. 	RACE 	113. NUM8ER 	OF 	{flm, 	-.d, 	etc.) 	14. 	EDUCAnON 	a.n-tary 	or Secondary 	I 	Colleg 	WIFE 	THIS 	MARRIAGE 	~onlyltig/IHI 	(0.12) 	I 	(1-4 	or~ 	I 	
15. 	USUAL 	(.net 	no. or~~ 	tt:IIM 	no.) 	(city 	or town)  (county-If 	not 	• ..,..,., 	clfy) 	t•teJ 	RESIDENCE 	
18. 	PlACE 	OF 	(cily 	or townl 	1_,.,1 	t•te 	or foreign 	coun1ryl 	17. 	DATE 	OF 	MARRIAGE 
MARRIAGE 	
18. 	NUMBER 	OF 	19. 	NUMBER 	OF 	CHILDREN 	UNDER 	18 WHOSE 	PHYSICAL 	CUSTODY 	WAS 	20. 	DATE 	OF 	SEPARATION 	CHILDREN 	UNDER 	18 	AWARDED 	TO: 	IN THIS 	FAMILY 	
21. 	PLAINTIFF 	Hulbend 	Wile 	
0 HUSBAND 	0 WIFE 	n BOTH 	Joint  (Hulband/Wilel  Other 	0 No c:llildr8n 	
22. 	DIVORCE 	GRANTED 	TO 	23. 	LEGAL 	GROUNDS 	OR 	CAUSE 	OF 	DIVORCE 	(If •nnulment • 	so .,.,.} 	
0 HUSBAND 	0 WIFE 	0 BOTH 	
24. 	INFORMANTS SIGNATURE 	..... 	OPEnnONER 0 ATTORNEY 	FOR 	PETITIONER 	
NAME 	OF 	=r:.~F 	INFORMANT {J)Ipe 	CK Print) 	
I CERTIFY 	THAT 	A FINAL 	DECREE 	OF 	WAS 	ENTERED 	CONCERNING 	THE 	AE 	(divon» 	or •nnulmentJ 	(Mie 	of dlliOI'ce 	or •nnulmentJ 	
MARRIAGE 	AND 	WAS 	NUMBERED 	..... 	
(CCIIXI 	tu. numtJer) 	SIGNATURE 	OF 	CLERK 	OF 	COURT 	OR 	DEPU 	
(SEAL) 	NAME 	OF 	CLERK 	OR 	DEPUTY 	{J)Ipe 	CK Print)