UDOH OVRS Form 404 at a glance
What it is: UDOH OVRS Form 404 is the State of Utah Department of Health Certificate of Divorce, Dissolution of Marriage, or Annulment.
Who signs: The certifying official signs in 29. SIGNATURE OF CERTIFYING OFFICIAL.
A filled-in UDOH OVRS Form 404 example: a certifying official completes the certificate for one divorce
How to fill out UDOH OVRS Form 404, box by box
Spouse 1 and Spouse 2: names, residence, birth, marriage, race and education
For SPOUSE 1, enter 1a. First Name, 1b. Middle Name, 1c. Last name before first marriage, if applicable, 1d. Last Name and 1e. Sex.
Enter 2a. RESIDENCE - CITY, TOWN OR LOCATION, 2b. COUNTY and 2c. STATE.
Enter 3. BIRTHPLACE (State or Foreign Country) and 4. BIRTHDATE (MM/DD/YY).
For SPOUSE 2, enter 9a. First Name, 9b. Middle Name, 9c. Last name before first marriage, if applicable, 9d. Last Name and 9e. Sex.
Enter 10a. RESIDENCE - CITY, TOWN OR LOCATION, 10b. COUNTY and 10c. STATE.
Enter 11. BIRTHPLACE (State or Foreign Country) and 12. BIRTHDATE (MM/DD/YY).
For SPOUSE 1, enter 5. NUMBER OF THIS MARRIAGE - First, Second, etc. (Specify) and, under 6. IF NOT FIRST MARRIAGE, LAST MARRIAGE ENDED:, Date (MM/DD/YY) and By Death, Divorce, Dissolution, or annulment (Specify). For SPOUSE 2, enter 13. NUMBER OF THIS MARRIAGE - First, Second, etc. (Specify) and, under 14. IF NOT FIRST MARRIAGE, LAST MARRIAGE ENDED:, Date (MM/DD/YY) and By Death, Divorce, Dissolution, or annulment (Specify).
Enter 7. RACE: White, Black, American Indian, etc. (Specify) and 15. RACE: White, Black, American Indian, etc. (Specify); enter 8. EDUCATION: (Specify only highest grade completed) and 16. EDUCATION: (Specify only highest grade completed) as Elementary/Secondary (0 - 12) or College (13-16 or 17+).
The marriage and the household
Enter 17a. PLACE OF THIS MARRIAGE - CITY TOWN, OR LOCATION, 17b. COUNTY, 17c. STATE OR FOREIGN COUNTRY and 18. DATE OF THIS MARRIAGE (MM/DD/YY).
Enter 19. DATE COUPLE LAST RESIDED IN SAME HOUSEHOLD (MM/DD/YY).
Enter 20. NUMBER OF CHILDREN UNDER 18 IN THIS HOUSEHOLD AS OF THE DATE IN ITEM 19, Number or None.
The petitioner and the petitioner's attorney
21. PETITIONER: Spouse 1, Both, Spouse 2 or Other, Specify.
Enter 22a. NAME OF PETITIONER'S ATTORNEY (Type/Print) and 22b. ADDRESS (Street and Number or Rural Route Number, City, or Town, State, Zip Code).
The decree and the custody of the children
Enter 23. "I certify that the marriage of the named persons was dissolved on (MM/DD/YY)."
Enter 24. TYPE OF DECREE, Divorce, Dissolution, or Annulment (Specify) and 25. DATE RECORDED (MM/DD/YY).
26. NUMBER OF CHILDREN UNDER 18 WHOSE PHYSICAL CUSTODY WAS AWARDED TO: Spouse 1, Spouse 2, Joint, Other, Not Determined Yet or No Children.
Enter 27. COUNTY OF DECREE and 28. TITLE OF COURT.
The certifying official
The certifying official signs in 29. SIGNATURE OF CERTIFYING OFFICIAL.
Enter 30. TITLE OF CERTIFYING OFFICIAL and 25. DATE SIGNED (MM/DD/YY).
Sources
[1] UDOH OVRS Form 404 (Rev. 01/16), Certificate of Divorce, Dissolution of Marriage, or Annulment, State of Utah Department of Health (the Official source link on this page).
