Affecting The Family Relationship Form PDF Details

In some cases, family relationships can be negatively affected when one or more of the parties are incarcerated. Incarceration can create a power dynamic in which the formerly incarcerated person feels powerless and the family members feel resentful. This resentment can manifest in different ways, such as through communication barriers or a refusal to support the formerly incarcerated individual. It is important for families to work through these issues and come to a mutual understanding in order to maintain healthy relationships. There are many resources available to help families affected by incarceration, including counseling and support groups. By utilizing these resources, families can learn how to effectively communicate and support each other despite any challenges they may face.

QuestionAnswer
Form NameAffecting The Family Relationship Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesvs form 165, texas vital statistics form vs 165, vital statistics form vs 165, form information family

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INFORMATION ON SUIT AFFECTING THE FAMILY RELATIONSHIP

(EXCLUDING ADOPTIONS)

SECTION I GENERAL INFORMATION (REQUIRED) STATE FILE NUMBER

1a. COUNTY __________________________ 1b. COURT NO. ________________________

1c. CAUSE NO. ________________________ 1d. DATE OF ORDER (mm/dd/yyyy) _________

2. TYPE OF ORDER (CHECK ALL THAT APPLY):

⃞ DIVORCE/ANNULMENT WITH CHILDREN (SeC. 1, 2 AND 3)

⃞ DIVORCE/ANNULMENT WITHOUT CHILDREN (Sec 1 AND 2)

⃞ESTABLISHMENT OF COURT OF CONTINUING JURISDICTION (SEC 1 AND 3)

(Court Order Establishing Paternity, Conservatorship, Child Support or Termination of Parental Rights)

⃞CHANGE IN THE NAME OF THE CHILD (SEC 1 AND 3)

(PROVIDE PRIOR AND NEW NAME OF CHILD IN SECTION 3)

⃞TRANSFER OF COURT OR CONTINUING JURISDICTION (SEC1, 3 AND INFORMATION BELOW) TRANSFER TO: COUNTY __________ COURT NO. ________ STATE COURT ID# ______________

3a. NAME OF ATTORNEY FOR PETITIONER

3b. TELEPHONE NUMBER (including area code)

3c. CURRENT MAILING ADDRESS (STREET AND NUMBER OR P.O BOX, CITY, STATE, ZIP)

SECTION 2 (IF APPLICABLE) REPORT OF DIVORCE OR ANNULMENT OF MARRIAGE

 

 

 

4. NAME (FIRST MIDDLE LAST SUFFIX)

 

 

 

 

 

 

5. MAIDEN LAST NAME (NAME BEFORE 1ST MARRIAGE)

 

ETITIONERP

 

 

 

 

 

 

 

 

 

 

 

 

6. PLACE OF BIRTH (CITY AND STATE OR FOREIGN COUNTRY)

 

 

7. RACE

 

8. DATE OF BIRTH (mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9. USUAL RESIDENCE

STREET NAME & NUMBER

 

CITY

STATE

 

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RESPONDENT

 

10. NAME (FIRST MIDDLE LAST SUFFIX)

 

 

 

 

 

 

11. MAIDEN LAST NAME (NAME BEFORE 1ST MARRIAGE)

 

 

 

 

 

 

 

 

 

 

 

 

 

12. PLACE OF BIRTH (CITY AND STATE OR FOREIGN COUNTRY)

 

 

13. RACE

 

14. DATE OF BIRTH (mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15. USUAL RESIDENCE (STREET AND NUMBER CITY, STATE, ZIP)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16. NUMBER OF MINOR CHILDREN

17. DATE OF MARRIAGE (mm/dd/yyyy)

18. PLACE OF MARRIAGE (CITY AND STATE OR FOREIGN COUNTRY)

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 3 (IF APPLICABLE) CHILDREN AFFECTED BY THIS SUIT

 

 

 

 

 

 

 

19a. CHILD CURRENT NAME (FIRST MIDDLE LAST SUFFIX)

 

 

 

 

 

 

 

1

 

 

 

 

 

 

 

 

 

 

 

 

 

19b. DATE OF BIRTH (mm/dd/yyyy)

 

19c. SEX

19d. BIRTHPLACE (CITY, COUNTY AND STATE)

 

CHILD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19e. PRIOR NAME OF CHILD (FIRST MIDDLE LAST SUFFIX) – IF APPLICABLE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20a. CHILD CURRENT NAME (FIRST MIDDLE LAST SUFFIX)

 

 

 

 

 

 

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

20b. DATE OF BIRTH (mm/dd/yyyy)

 

20c. SEX

20d. BIRTHPLACE (CITY, COUNTY AND STATE)

 

CHILD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20e. PRIOR NAME OF CHILD (FIRST MIDDLE LAST SUFFIX) – IF APPLICABLE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21a. CHILD CURRENT NAME (FIRST MIDDLE LAST SUFFIX)

 

 

 

 

 

 

 

3

 

 

 

 

 

 

 

 

 

 

 

 

 

21b. DATE OF BIRTH (mm/dd/yyyy)

 

21c. SEX

21d. BIRTHPLACE (CITY, COUNTY AND STATE)

 

CHILD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21e. PRIOR NAME OF CHILD (FIRST MIDDLE LAST SUFFIX) – IF APPLICABLE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDITIONAL CHILDREN LISTED ON BACK OF THIS FORM.

 

 

 

 

 

 

I CERTIFY THAT THE ABOVE ORDER WAS GRANTED ON THE DATE AND PLACE AS STATED.

_____________________________________

 

 

 

 

 

 

 

 

 

 

 

SIGNATURE OF THE CLERK OF THE COURT

WARNING: This is a governmental document. Texas Penal Code, Section 37.10, specifies penalties for making false entries or providing false information in this document. VS-165 REV 07/2017

Texas Department of State Health Services - Vital Statistics

VS-165 REV 07/2017

1

 

 

ADDITIONAL CHILDREN AFFECTED BY THIS SUIT FROM SECTION 3 (IF APPLICABLE)

 

23a. CHILD CURRENT NAME (FIRST MIDDLE LAST SUFFIX)

 

4

 

 

 

23b. DATE OF BIRTH (mm/dd/yyyy)

23c. SEX

23d. BIRTHPLACE (CITY, COUNTY AND STATE)

CHILD

 

 

 

 

23e. PRIOR NAME OF CHILD (FIRST MIDDLE LAST SUFFIX) – IF APPLICABLE

 

 

 

 

24a. CHILD CURRENT NAME (FIRST MIDDLE LAST SUFFIX)

 

5

 

 

 

24b. DATE OF BIRTH (mm/dd/yyyy)

24c. SEX

24d. BIRTHPLACE (CITY, COUNTY AND STATE)

CHILD

 

 

 

 

24e. PRIOR NAME OF CHILD (FIRST MIDDLE LAST SUFFIX) – IF APPLICABLE

 

 

 

 

25a. CHILD CURRENT NAME (FIRST MIDDLE LAST SUFFIX)

 

6

 

 

 

25b. DATE OF BIRTH (mm/dd/yyyy)

25c. SEX

25d. BIRTHPLACE (CITY, COUNTY AND STATE)

CHILD

 

 

 

 

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 reporting 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 INFORMATION (REQUIRED)

This section must be completed for each report filed.

ｸ1a – d. Enter the required information to identify the court proceeding.

ｸ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”).

ｸ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.

ｸ4-9. Report the Petitioner’s information including maiden name (if applicable).

ｸ10-15. Report the Respondent’s information, including maiden name (if applicable).

ｸ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.

ｸ17-18. Enter the date and place of the marriage being dissolved.

SECTION 3 (IF APPLICABLE) 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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2. Once the last segment is finished, you should add the necessary details in R E N O T T E P, USUAL RESIDENCE, STREET NAME NUMBER, CITY, STATE, ZIP, NAME FIRST MIDDLE LAST SUFFIX T N, PLACE OF BIRTH CITY AND STATE OR, USUAL RESIDENCE STREET AND NUMBER, MAIDEN LAST NAME NAME BEFORE ST, RACE, DATE OF BIRTH mmddyyyy, NUMBER OF MINOR CHILDREN, DATE OF MARRIAGE mmddyyyy, and PLACE OF MARRIAGE CITY AND STATE so you can progress further.

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3. Your next part is going to be easy - fill out all the blanks in cid ADDITIONAL CHILDREN LISTED ON, I CERTIFY THAT THE ABOVE ORDER WAS, SIGNATURE OF THE CLERK OF THE COURT, WARNING This is a governmental, Texas Department of State Health, and VS REV in order to complete this process.

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4. Filling out ADDITIONAL CHILDREN AFFECTED BY, a CHILD CURRENT NAME FIRST MIDDLE, b DATE OF BIRTH mmddyyyy, c SEX, d BIRTHPLACE CITY COUNTY AND STATE, e PRIOR NAME OF CHILD FIRST MIDDLE, a CHILD CURRENT NAME FIRST MIDDLE, b DATE OF BIRTH mmddyyyy, c SEX, d BIRTHPLACE CITY COUNTY AND STATE, e PRIOR NAME OF CHILD FIRST MIDDLE, a CHILD CURRENT NAME FIRST MIDDLE, b DATE OF BIRTH mmddyyyy, c SEX, and d BIRTHPLACE CITY COUNTY AND STATE is crucial in this fourth step - be sure to take your time and take a close look at every single blank area!

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5. The last notch to finalize this PDF form is crucial. You need to fill out the displayed blanks, consisting of For information concerning, The VSU form must be printed, SECTION GENERAL INFORMATION, This section must be completed for, a d Enter the required, Check the type of suit being, a c Complete the attorney, SECTION IF APPLICABLE REPORT OF, All divorcesannulments must be, Report the Petitioners, Report the Respondents, Report the number of minor, Enter the date and place of the, and SECTION IF APPLICABLE CHILDREN, prior to finalizing. Otherwise, it can lead to an incomplete and possibly invalid form!

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