"Application for Certified Copy of Vermont Marriage or Divorce or Civil Union Dissolution Certificate" - Vermont

Application for Certified Copy of Vermont Marriage or Divorce or Civil Union Dissolution Certificate is a legal document that was released by the Vermont Department of Health - a government authority operating within Vermont.

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Application for Certified Copy of Vermont Marriage or Divorce or
Civil Union Dissolution Certificate
Vital Records Office
PO Box 70
Burlington, VT 05402
USE THIS FORM FOR EVENTS OCCURRING FROM 2014 – PRESENT ONLY*
*Civil Union Dissolutions Certificates for all years.
CERTIFICATES PRIOR TO 2014 CAN BE ORDERED FROM
THE VERMONT STATE ARCHIVES AND RECORDS ADMINISTRATION (VSARA)
INDIVIDUAL REQUESTING THE CERTIFICATE:
Name:
___________________________________________________
Street Address: ___________________________________________________
City:
____________________________ State: ________________ Zip: ____________________
Daytime Phone:__(_____)___________________ Email Address: ___________________________________
Relationship to person named on certificate:
________________________________________________
Purpose of request: ☐Social Security
☐School Enrollment ☐Passport
☐Driver’s License
☐Family History
☐Other (specify): ______________________________
CIVIL MARRIAGE CERTIFICATE
Number of Copies Requested_______ x $10 each
Name of Party A: _________________________________ Date of Marriage: ___________________________
Name of Party B: _________________________________
DIVORCE/DISSOLUTION CERTIFICATE
Number of Copies Requested_______ x $10 each
Name of Party A: _________________________________ Date of Divorce/Dissolution: __________________
Name of Party B: _________________________________
Total Number of Certificates Ordered: _______
Cost Each: ___$10.00___
Order Total:
$___________
Make checks or money orders (U.S. funds) payable to the Vermont Department of Health and mail your
payment with this form and a self-addressed envelope to the address shown above.
__________________________________________________________________________________________
FOR OFFICIAL USE ONLY:
CID: _________________
CPA-B:_____________________
CPA-E:______________________
Application for Certified Copy of Vermont Marriage or Divorce or
Civil Union Dissolution Certificate
Vital Records Office
PO Box 70
Burlington, VT 05402
USE THIS FORM FOR EVENTS OCCURRING FROM 2014 – PRESENT ONLY*
*Civil Union Dissolutions Certificates for all years.
CERTIFICATES PRIOR TO 2014 CAN BE ORDERED FROM
THE VERMONT STATE ARCHIVES AND RECORDS ADMINISTRATION (VSARA)
INDIVIDUAL REQUESTING THE CERTIFICATE:
Name:
___________________________________________________
Street Address: ___________________________________________________
City:
____________________________ State: ________________ Zip: ____________________
Daytime Phone:__(_____)___________________ Email Address: ___________________________________
Relationship to person named on certificate:
________________________________________________
Purpose of request: ☐Social Security
☐School Enrollment ☐Passport
☐Driver’s License
☐Family History
☐Other (specify): ______________________________
CIVIL MARRIAGE CERTIFICATE
Number of Copies Requested_______ x $10 each
Name of Party A: _________________________________ Date of Marriage: ___________________________
Name of Party B: _________________________________
DIVORCE/DISSOLUTION CERTIFICATE
Number of Copies Requested_______ x $10 each
Name of Party A: _________________________________ Date of Divorce/Dissolution: __________________
Name of Party B: _________________________________
Total Number of Certificates Ordered: _______
Cost Each: ___$10.00___
Order Total:
$___________
Make checks or money orders (U.S. funds) payable to the Vermont Department of Health and mail your
payment with this form and a self-addressed envelope to the address shown above.
__________________________________________________________________________________________
FOR OFFICIAL USE ONLY:
CID: _________________
CPA-B:_____________________
CPA-E:______________________