Nebraska Hhs 73 Form PDF Details

The Nebraska HHS 73 form serves as a vital document within the state's Department of Health and Human Services, specifically within the realm of Finance and Support Vital Records. It is intricately designed to record the details of dissolutions of marriage or annulments processed within the jurisdiction of Nebraska. This comprehensive form captures a wide range of data, including the county or tribal court details, court record numbers, and the certification of the dissolution or annulment of marriage. It requires personal information from both parties, such as names, current residences, places of birth, dates of birth, and details regarding the marriage like the place and date of marriage. Additionally, the form touches upon matters involving children under 18, detailing custody arrangements and the number of children affected. Financial and support arrangements post-dissolution or annulment, such as alimony, child support, property settlement, and medical reimbursement, are also addressed. Furthermore, it collects demographic information, including social security numbers, Hispanic or Latino origin, and racial identification, providing a comprehensive snapshot of the individuals involved. The Nebraska HHS 73 form is critical for accurate record-keeping and administrative purposes, ensuring that all aspects of the dissolution or annulment are meticulously documented for the state records.

QuestionAnswer
Form NameNebraska Hhs 73 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names11d, nebraska hhs 73 55073, rk, 20b

Form Preview Example

1.฀฀County/Tribal฀Court฀฀฀฀฀฀฀฀State฀of฀Nebraska

Department฀of฀Health฀and฀Human฀Services฀Finance฀and฀Support

Vital฀Records

฀฀2.฀฀Court฀Record฀Number฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀cate฀of฀Dissolution฀of฀Marriage฀or฀Annulment

Certifi

WORKSHEET฀ONLY

฀฀3.฀฀Husband’s฀Name฀(First,฀Middle,฀Last,฀Suffi฀x)

฀฀4a.฀฀Current฀Residence฀-฀Country฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀ ฀ ฀ ฀ ฀

4b.฀฀State฀ ฀ ฀ ฀

4c.฀฀County

฀฀4d.฀City,฀Town฀or฀Location฀฀ ฀ ฀ ฀ ฀

4e.฀฀Residence฀-฀Street฀and฀Number฀ ฀ ฀ ฀

4f.฀฀Zip฀Code

฀฀5.฀฀Place฀of฀Birth฀(City฀and฀State฀or฀Foreign฀Country)฀฀ ฀ ฀ ฀ ฀ ฀

6.฀฀Date฀of฀Birth฀(Mo.,฀Day,฀Yr.)

฀฀7a.฀฀Wife’s฀Name฀(First,฀Middle,฀Last,฀Suffi฀x)฀฀ ฀

฀฀8a.฀฀Current฀Residence฀-฀Country฀฀

8b.฀฀State฀฀ ฀

8c.฀฀County

฀฀฀8d.฀City,฀Town฀or฀Location฀฀ ฀ ฀ ฀ ฀

฀8e.฀฀Residence฀-฀Street฀and฀Number฀ ฀ ฀ ฀

8f.฀฀Zip฀Code

฀฀9.฀฀Place฀of฀Birth฀(City฀and฀State฀or฀Foreign฀Country)฀฀ ฀ ฀ ฀ ฀ ฀

10.฀฀Date฀of฀Birth฀(Mo.,฀Day,฀Yr.)

 

฀11a.฀฀Place฀of฀Marriage฀-฀State฀

11b

.฀฀County฀฀฀

฀฀฀฀

 

฀฀฀฀฀฀฀฀฀฀฀฀

11c.฀฀City฀

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11d.฀฀Date฀of฀Marriage

฀(Mo.,฀Day,฀Yr.)

฀฀12a.฀฀Number฀of฀Children฀under฀18฀in฀this฀Household฀฀

฀฀12b.฀฀Number฀of฀Children฀Under฀18฀Whose฀Physical฀Custody฀was฀Awarded฀to:

 

 

 

 

 

 

฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀

 

Husband฀฀฀฀฀฀฀฀฀

Wife฀฀฀฀฀฀฀฀฀฀฀฀฀

Joint฀Husband/Wife฀

฀฀฀฀฀฀฀฀฀฀฀Number

 

 

 

 

 

 

฀฀

฀฀฀฀฀฀฀฀฀฀฀

 

Other

 

_______________฀฀฀฀฀฀

฀฀

฀฀

฀฀

฀฀

฀฀

฀฀

฀฀

฀฀

฀฀

 

฀No฀Children฀Awarded฀Custody฀

 

฀13.฀฀Plaintiff฀฀฀

฀฀14.฀฀List฀Former฀Name฀of฀Wife,฀if฀restored

 

 

฀฀Husband฀฀฀฀ ฀฀Wife฀

 

 

 

 

 

 

 

 

 

 

 

฀15a.฀฀Attorney฀for฀Plaintiff฀-฀Name฀

฀฀

15b.฀฀Address฀(Street,฀City฀or฀Town,฀State฀and฀Zip฀Code)

฀฀16a.฀฀I฀certify฀that฀the฀marriage฀of฀the฀above฀name฀persons฀was฀dissolved฀on฀฀ ฀

 

16b.฀฀Type฀of฀Decree

฀฀฀฀฀฀฀฀฀฀฀(Mo.,฀Day,฀Yr.)฀฀

 

฀฀฀฀฀฀฀฀฀฀______Dissolution฀฀฀฀฀฀______Annulment

 

฀17.฀฀Clerk฀of฀the฀District฀Court฀or฀Tribal฀Court฀Making฀Return฀to฀the฀Department฀of฀Health฀and฀Human฀Services฀Finance฀and฀Support

฀Information฀For฀Administrative฀Use฀Only.฀Information฀below฀will฀not฀appear฀on฀certifi฀ed฀copies฀of฀the฀record

18.฀฀Settlement(s)฀Made

฀฀฀฀฀฀฀฀฀฀Alimony ฀Yes฀ ฀No฀฀฀฀฀฀Child฀Support฀ ฀฀Yes ฀฀No฀฀฀฀฀฀฀Property฀Settlement฀ ฀฀Yes฀ ฀No฀฀฀฀฀฀฀Medical฀Reimbursement฀ ฀฀Yes฀ ฀฀No

19.฀฀Social฀Security฀Numbers

Husband: ฀฀Wife:

20a.

Is Husband of Hispanic or Latino Origin?

฀฀Yes฀฀ ฀฀No

20b. Is Wife of Hispanic or Latina Origin?

฀฀Yes฀฀ ฀฀No

 

21a. Husband

Race

 

21b. Wife

 

Check the race(s) each person considers him/herself to be

 

 

 

White/Caucasian

 

 

 

Black or African American

 

 

American Indian or Alaska Native

 

 

Asian

 

 

 

Native Hawaiian or Other Pacifi c Islander

 

HHS-73฀(55073)฀6/06

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20b completion process explained (portion 1)

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Writing segment 3 in 20b

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