Address: City/State: Zip:
Self Father Paternal Uncle
Mother Brother Maternal Uncle
Last Name Prior to First Marriage (if different)
Check one: Husband Wife Spouse Date of Birth:
FIRST MIDDLE LAST Last Name Prior to First Marriage (if different)
Check one: Wife Husband Spouse
*Requirements-Read before turning in application
1) This request form must be completed.
2) Enclose a copy of both front and back of a current legal photo ID
(see back for list of acceptable ID's)
3) Enclose appropriate fees
4) Person requesting to receive a certificate must sign above.
5) If submitting by mail, enclose a self-addressed stamped envelope
*Request will be returned if the above steps are not completed correctly.
County that granted Divorce:
COUNTY STATE(MUST BE KANSAS)
Application for Certified Copy of Kansas Divorce Certificate
* IF THE CERTIFICATE IS NOT LOCATED, A $15.00 FEE
BY THIS DEPARTMENT FOR THE RECORD SEARCH
Make checks or money orders payable to Kansas Vital Statistics. For your protection, do not send cash.
K.A.R. 28-17-6 requires the following fee(s).
The correct fee must be submitted with the request. The fee for certified copies of divorce certificates is $15.00 for each certified copy. This fee allows a 5-
year search of the records, including the year indicated plus two years before and two years after, or you may indicate the consecutive 5-year period you want
searched. You may specify more than one 5-year span, but each search will cost $15.00.
(person requesting the certificate)
City that Divorce took place:
$15 per Certified Copy
Number of Copies Ordered:
Name on Record:
FIRST MIDDLE LAST
Office hours:(live phones)
Kansas Office of Vital Statistics
Mon-Fri 8:00a.m.-5:00 p.m.
1000 SW Jackson Suite 120
Station/# of apps __________________________ Exp __________________
Payment Type CASH CHECK CCARD MO
OFFICE USE ONLY
* PLEASE NOTE DIVORCE CERTIFICATES ARE ON FILE FROM July 1, 1951 TO PRESENT
Legal Guardian(submit custody order)
*IMPORTANT: The person requesting the vital record must submit a copy of their identification. See list on reverse side.
Requestor's relationship to person on the Certificate? (Check one)
Reason for Request (PLEASE BE SPECIFIC):
Name of Record: