Dhhs Form Hhs 95 PDF Details

The DHHS HHS-95 form serves as a critical piece of documentation for individuals seeking to obtain a certified copy of a Dissolution of Marriage (Divorce) Certificate in Nebraska. Since 1909, the office has been tasked with registering dissolutions of marriages occurring within the state. For those instances predating 1909 or in cases where an individual needs the actual divorce decree, the form directs applicants to the District Court of the county where the divorce was finalized. Applicants are required to provide comprehensive details such as the full names of both spouses, the location (city or county) where the divorce was granted, and the exact date of the dissolution. Importantly, the form also inquires about the intended use of the record and the applicant's relationship to the persons named on it, underscoring the government's effort to limit the use of these sensitive documents for deceptive purposes. A warning is explicitly stated regarding the legal consequences of misusing vital records, emphasizing the importance of integrity in handling such documents. To complete the application process, the form outlines the need for a photocopy of a photo ID, the associated fees, and payment instructions, providing a clear pathway for applicants to follow. Furthermore, the form identifies both a mailing address and an in-person submission location, offering flexibility in submission methods. It reinforces the procedural requirements and legal framework designed to safeguard personal information, highlighting the balance between accessibility of public records and protection of individual privacy.

QuestionAnswer
Form NameDhhs Form Hhs 95
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesdivorce pdf form nebraska application for certified copy of dissolution of marriage

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APPLICATION FOR CERTIFIED COPY OF DISSOLUTION OF MARRIAGE (DIVORCE) CERTIFICATE

This office has been registering dissolutions of marriage (divorces) occurring in Nebraska since 1909. For records occurring prior to 1909, or if you wish to obtain the divorce decree, contact the District Court in the county where the divorce was granted.)

PLEASE TYPE OR PRINT LEGIBLY

Full name of husband _________________________________________________________________________________

Full name of wife _____________________________________________________________________________________

City or county where granted ____________________________________________________________________________

Month, day, and year granted ___________________________________________________________________________

For what purpose is this record to be used? ________________________________________________________________

If this is not your divorce certificate, how are you related to the person listed on the record? __________________________

WARNING: Section 71-649, Nebraska Revised Statutes: It is a felony to obtain, possess, use, sell, furnish, or attempt to obtain any vital record for purposes of deception.

SIGNATURE _____________________________________________

Type or print name_________________________________________

Street Address____________________________________________

City, State, Zip ___________________________________________

Daytime Telephone Number _________________________________

Email Address ___________________________________________

Today’s Date _____________________________________________

Please enclose a photocopy of your photo ID (i.e. current driver’s license) when mailing in this request.

Fees are subject to change without notice. Please call our 24-hour recorded message at (402) 471-2871 to verify fees.

Number of certified copies________ x $16.00 each = $________ Total

(Please make checks payable to Vital Records)

Mail to:

Bring to:

Vital Records

Vital Records

PO Box 95065

1033 O Street, Suite 130

Lincoln, NE 68509-5065

Lincoln, NE 68508-3621

(Please enclose a stamped,

 

self-addressed business

 

size envelope.)

 

FOR OFFICE USE ONLY

 

q Check q MO

q Cash

Amount Received ________________________

Date Received __________________________

By Whom Received ______________________

PROOF OF IDENTIFICATION;

 

DL

STATE ID

OTHER

______________________________________

HHS-95 (55097) 6/14

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