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                                                                   ARKANSAS DEPARTMENT OF HEALTH
                                                                        Vital Records Section - 44
 DATE
                                                                           4815 West Markham
                                                                         Little Rock, AR 72205

                                                            DIVORCE RECORD APPLICATION
Only Arkansas events of divorce are filed in this office. Divorce records start with 1923. The fee is $10.00 for each copy requested. This fee must
accompany the application. Send check or money order payable to the Department of Health. DO NOT SEND CASH. $10.00 will be kept to cover the
search charge when the record is not located in our files. Please allow 4 - 6 weeks for delivery.



                                                  FILL IN FOR A DIVORCE RECORD

NAME OF HUSBAND

NAME OF WIFE

DATE OF DIVORCE OR DISMISSAL
                                                       Month                                    Day                                        Year

COUNTY IN WHICH DIVORCE WAS GRANTED/DISMISSED



               PLEASE ANSWER ALL QUESTIONS                                                                         DO NOT WRITE IN THIS SPACE

What is your relationship to the parties named on the requested record?                                Searcher

                                                                                                       Index



What is your reason for requesting a copy of this record?

                                                                                                       Volume No.

Signature and telephone number of person requesting this certificate:                                  Page No.                                        Yr.




 Certificates may also be ordered by the following methods:

                                                                                                      CERTIFIED COPY (S)
 Internet: www.expressvitalrecords.com or www.vitalchek.com . The                                     Each copy is $10.00                               HOW MANY
 service fee and the certificate fee are charged to your debit or credit card. (Visa, Master
                                                                                                                                              HOW MANY
 Card, Discover and American Express. Overnight shipping is available for an additional fee.
                                                OR
 Telephone: Toll free (888) 803-1118 or (866) 209-9482. The service fee and the certificate
 fee are charged to your debit or credit card. (Visa, Master Card, Discover or American
 Express) Overnight shipping is available for an additional fee.
                                                OR                                                    AMOUNT OF(S)
                                                                                                        COPY MONEY ENCLOSED $______
 Walk in: The certificate may be ordered by coming into this office. If you want the copy the
 same day, our hours for same day service are 8:00 A.M. until 3:00 P.M. Monday ­ Friday.
 The office is located at 4815 West Markham St Little Rock, AR 72205. Please order family             Each copy costs $5.00
 history and genealogy by mail or Internet.                                                           AMOUNT OF MONEY ENCLOSED $




Please PRINT below the name and address of the
person who is to receive the copy(s).
                                                                                                  Any person who willfully and knowingly makes any false statement in an
                                                                                                  application for a certified copy of a vital record filed in this state is subject
NAME                                                                                              to a fine of not more than ten thousand dollars ($10,000) or imprisoned
                                                                                                  not more than five (5) years, or both (Arkansas Statutes 20-18-105.)

ADDRESS


CITY                                               STATE                  ZIP
VR-10 (R 8/07)