STATE OF GEORGIA

Report of Divorce, Annulment or Dissolution of Marriage Type or Print all Information

1. Civil Action Number l. D111,• Dcrrcc Grnuicd (1110.,tla�·,yrar) 3. Coun�· Decree Grunted

4. Wife's N11111c (first, middlc, Inst) 5. l\laidc11 (Birth) Last Nnmc 6. DM� of Birth {1110 .. t111.,\''et11·)

7. County of Residence 8. Nnml>er of This M11rriagc (l'', 2nd• etc,)

9. Hushand's Name (first, middle, last, IO. Dair of Birth (1110 .. day,,·rnr) 11. Countf of Resideuce

gcnerntion)

12. Number of This Mnrringe (1", 2nd, etc.) 13. Dnte of Thii; Maninge (mo., day, y«rnr)

14. Specifiy Grounds for Divorce (19-5-3, OCGA) 15. �111111.>rr of Children Less Than 18 Affocced by chis necrce

I

This above Report may be reproduced by use of a computer. However, the finished reproduction must be a close reproduction of the original, and prior review and approval must be obtained from the State Registrar before use.

(31-10-7, O.C.G.A.)

J 1-10-22. Rco.:urd of divorce. dissolucions, and mmulmcnts.

(a) A record of each divorce, dissolution or mc1rriagc, or annulment grantedby any couit of compelent jurisdiction in this state shall be filed by the clerkof the court with the department and shall be registered if it has beencompleted and filed in accordance with this Code section. The record shallbe prepared bv the petitioner or the petitioner's legal representative on afonn prescribed and furnished by the state registrar and shall be presented tothe clerk of cour1 with the petition. In nil cases, the completed record shallbe a prerequisite to the granting of the final decree.

(b) The clerk of the superior cou1t shall complete and forward to thedepm1menl on or before the tenth day of each calendar month the records ofeach divorce. dissolution of marriage, or annulment decree granted duringthe preceding cnlendm· monlh.