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INFORMA TJON ON SUIT AFFECTING THE FAMILY RELATIONSHIP
(EXCLUDING ADOPTIONS)
SECTION I GENERAL INFORMATION (REQUIRED) STATE FILE NUMBER
1a. COUNTY _,'J'"'a"-'rra"""ntc..__ _ _ _ __
1b. COURT NO. _,3"'60"'t"'h_ _ _ _ _,........,
1c. CAUSE NO.360-543013-13 1d. DATE OF ORDER (mm/ddlyyyy) II I/1 //J.D flJ)
2. TYPE OF ORDER (CHECK ALL THAT APPLY):
DIVORCE/ANNULMENT WITH CHILDREN (Sec. 1;2 AND 3) DIVORCE/ANNULMENT WITHOUT CHILDREN (Sec 1 AND 2)
XESTABLISHMENT OF COURT OF CONTINUING JURISDICTION (SEC 1 AND 3)
(Court Order Establishing Paternity, Conservatorship, Child Support or Termination of Parental Rights)
_CHANGE IN THE NAME OF THE CHILD (SEC 1 AND 3)
(PROVIDE PRIOR AND NEW NAME OF CHILD IN SECTION 3}
TRANSFER OF COURT OR CONTINUING JURISDICTION (SEC1,3 AND INFORMATION BELow)
TRANSFER TO COUNTY COURT NO STATE COURT ID#
3a. NAME Of ATIORNEY FOR PETITIONER 13b. TElEPHONE NUMBER (including area eode)
TURNER-MONAHAN, PLLC (817) 332-4477
3C. CURRENT MAILING ADDRESS {STREET AND NUMBER OR P.O BOX, CITY, STATE, ZIP)
100 Throckmorton, Suite 170 Fort Worth Texas 76102
SECTION 2_(1F APPLICABLE) REPORT OF DIVORCE OR ANNULMENT OF MARRIAGE
4. NAME (FIRST t.fi!XXE LAST SUFFix} 1"' MARRIAGE)
5. MAIDEN LAST NAME (NAME BEFORE
"'zw 8. DATE OF BIRTH (nm'c.tVy)'yy)
0
I=
6. PLACE OF BIRTH {CITY AND STATE OR FOREIGN COUNTRY)
17 RACE
I=
w 9. USUAl RESIDENCE I.
STREET NAME NUMBER CITY STATE VP
0..
10. NAME (ARST M1DDLE LAST SUFFix) 11. MAlDEN lAST N.l.ME {NAME. BEFORE 1cr MARRIAGE)
...z
w
c 12.PlACE Of BIRTH {OTY AND STATE OR FOREIGN COI.IJTRY) 113. RACE 14. DATE Of BIRTH (mnlkWyy}y)
~
"'w 15. USUAL RESIDENCE {STREET AND NUMBER CITY, STATE, ZIP}
"' 117.
16. NUMBER OF MINOR CHIU~EN 118.
DATE OF MARRIAGe (ITIIMXVy)'yy) (aTY ANOST... TEORFORfiGNCOl.NTRY}
PlACE Of MARRIAGE
lf'ARI ~~CHILDREN
I 3 (IF ,ADDI AFFECTED BY THIS SUIT
BRODm~';:;:;;;d~"WAnE~" '"' ,,
-9 BIRTH
11/01/2007
19o. SEX
Male
'
Arlington
... .,
Tarrant Texas
~
I ;oF• I
I :':.
GR.tu "v1-i DANIEL WADE
N 20b. DATE OF BIRTH 20c. sex 20d.l '(CITY. t
g 08/03/2009 Male J'l.HUI!\IUII Tarrant Texas
20e.l ' I
21 a. CHILD CURRENT
RHYDER COLE WADE
.., 21b. OATEOFetRTH I 210. SEX 21d. BIRTHPlACE (CITY, (X)I.JNTY AND STATE}
9
,_. v
08118/2011 Male Arlington Tarrant Texas
'u 21e.1
....
...-~~ ~~--
_"""·~·--·
I CERTIFY THAT THE ABOVE ORDER WAS GRANTED ON THE DATE AND '~-_; CftVJIUf
SIGNATURE OF THE CLERK OF THE COURT
WARNING: This Is a governmental document. Texas Penal Code, Section 37.10, specines penalties for making false entries or
providing false information in this document
VS-165 REV 0712015
Texas Department of State Heahh Services- Vital Statistics VS-165 REV 0712015
1
__
.,, ,,,_,.. _,,
•• r-'00. --·-- -·
.. ...._
,,,_ --··. ''"-'" ... --··-· .. -
~
--
23a. CHILD CURRENT tw.4E {FIRST MIDDLE LAST SUFFIX)
"'~ 23b. DATE Of BIRTH (rnm'dd)':r»}
T23c.SEX 123d. BIRTH'I.ACE {CITY,
CCXNTY AND STATE)
•u
23e. PRIOR NAME OF CHILD (FIRST lrfDDt.E LAST SUFFix) -IF APPUCABLE
f
24a. CHILD CURRENT NAME (FIRST MIDDLE LAST SUFFix)
"'9 2<4b. DATE Of BIRTH (mm'dCVy)')y)
T24c.SEX I 24d. BIRTHPLACE (cnv,_cotJNTl' AND STArE)
•
u
248. PRIOR NAME OF O"tiLO {FIRST MionE LAST SUFFix) -IF APPLICABLE
25a. CHILD CURRENT KAME (FIRST lrfiOCU LAST SUFFix)
c 25b. DATE Of BIRTH (fTVTII'ddlyyyy)
125c.SEX -r 25d. BIRTt-FLACE {CITY, COUNTY AND STATE)
g
25e. PRIOR NAME Of CHILO (FIRST MIDDLE LAST SUFFIX) -IF APPUCABLE
'
Instructions for Completing the Suit Affecting Parent Child Relationship Form
GENERAL REQUIREMENT:
All divorces/annulments (with or without children) and all suits affecting the parent-child relationship must be reported through the clerk ofthe
court to the State Vrtal Statistics Un~ (VSU).
Consolidated reporting by petitioners, attorneys, and the courts is designed to make mandatory reporting more efficient, timely, and Improve
the quality of reporting.
However, this reporting system is only as good or timely as you make It: therefore, your attention in completing and
filing this report is critical.
legal basis for this reporting is contained in Heanh and Safety Code §194.002 and Texas Family Code §§108.001-.002 and 108.004.
For infonnation concerning reporting or questions about this form, contact field services at fieldservices@dshs.texas.gov or by phone at 512-
776-7368.
For information on the court of continuing jurisdiction of a child, contact VSU at {888) 96~7111 ext. 2529. Inquiries should be addressed to
VSU, 1100 West 49"' Street, Austin, Texas. 78756-Jt 9t; inquiries may also be faxed to (5t2) 456-n83.
SECTION 1 GENERAL INFORMATION (REQUIRED)
This section must be completed for each report filed.
• 1a- d. Enter the required Information to identify the court proceeding.
• 2. Check the type of suit being reported. This determines also which sections ofthe form must be completed. If more than one type of
order applies, check aU that apply. Transfers from one jurisdidion to another must be reported in this section (if court number is unknown,
specify •unknown~).
• 3a- c. Complete the attorney Information to assist In questions or follow up. If case was prose. p4ease enter the lnfonnatlon of the
person completing this form.
SECTION 2 (IF APPUCABLE) REPORT OF DIVORCE OR ANNULMENT OF MARRIAGE
All divorces/annulments must be reported, even if there were no minor children. AU information is required.
• 4-9. Report the Petitioner's information Including maiden nama {if applicable).
• 10-15. Report the Respondent's information, including maiden name (if applicable).
• 16. Report the number of minor children affected by this divorce; if none, record "O: This number must correspond to the listing of
children in Section 3.
• 17-18. Enter the date and place of the marriage being dissolved.
SECTION 3 (IF APPUCABLE) CHILDREN AFFECTED BY THIS SUIT
Every child affected by the suit being reported must be listed, and all items concerning that child must be completed. If more than three children are
affected, check the "additional children listed on back of fonn· box, and continue to list the additional children.
If more than 6 children complete
section 3 on another form, label it "continuation• and attached the continuation fonn to the original form.
Texas Department ol State Health Services- VItal Statistics VS·165 REV 0712015
2
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INFORMA TJON ON SUIT AFFECTING THE FAMILY RELATIONSHIP (EXCLUDING ADOPTIONS) SECTION I GENERAL INFORMATION (REQUIRED) STATE FILE NUMBER 1a. COUNTY _,'J'"'a"-'rra"""ntc..__ _ _ _ __ 1b. COURT NO. _,3"'60"'t"'h_ _ _ _ _,........, 1c. CAUSE NO.360-543013-13 1d. DATE OF ORDER (mm/ddlyyyy) II I/1 //J.D flJ) 2. TYPE OF ORDER (CHECK ALL THAT APPLY): DIVORCE/ANNULMENT WITH CHILDREN (Sec. 1;2 AND 3) DIVORCE/ANNULMENT WITHOUT CHILDREN (Sec 1 AND 2) XESTABLISHMENT OF COURT OF CONTINUING JURISDICTION (SEC 1 AND 3) (Court Order Establishing Paternity, Conservatorship, Child Support or Termination of Parental Rights) _CHANGE IN THE NAME OF THE CHILD (SEC 1 AND 3) (PROVIDE PRIOR AND NEW NAME OF CHILD IN SECTION 3} TRANSFER OF COURT OR CONTINUING JURISDICTION (SEC1,3 AND INFORMATION BELow) TRANSFER TO COUNTY COURT NO STATE COURT ID# 3a. NAME Of ATIORNEY FOR PETITIONER 13b. TElEPHONE NUMBER (including area eode) TURNER-MONAHAN, PLLC (817) 332-4477 3C. CURRENT MAILING ADDRESS {STREET AND NUMBER OR P.O BOX, CITY, STATE, ZIP) 100 Throckmorton, Suite 170 Fort Worth Texas 76102 SECTION 2_(1F APPLICABLE) REPORT OF DIVORCE OR ANNULMENT OF MARRIAGE 4. NAME (FIRST t.fi!XXE LAST SUFFix} 1"' MARRIAGE) 5. MAIDEN LAST NAME (NAME BEFORE "'zw 8. DATE OF BIRTH (nm'c.tVy)'yy) 0 I= 6. PLACE OF BIRTH {CITY AND STATE OR FOREIGN COUNTRY) 17 RACE I= w 9. USUAl RESIDENCE I. STREET NAME NUMBER CITY STATE VP 0.. 10. NAME (ARST M1DDLE LAST SUFFix) 11. MAlDEN lAST N.l.ME {NAME. BEFORE 1cr MARRIAGE) ...z w c 12.PlACE Of BIRTH {OTY AND STATE OR FOREIGN COI.IJTRY) 113. RACE 14. DATE Of BIRTH (mnlkWyy}y) ~ "'w 15. USUAL RESIDENCE {STREET AND NUMBER CITY, STATE, ZIP} "' 117. 16. NUMBER OF MINOR CHIU~EN 118. DATE OF MARRIAGe (ITIIMXVy)'yy) (aTY ANOST... TEORFORfiGNCOl.NTRY} PlACE Of MARRIAGE lf'ARI ~~CHILDREN I 3 (IF ,ADDI AFFECTED BY THIS SUIT BRODm~';:;:;;;d~"WAnE~" '"' ,, -9 BIRTH 11/01/2007 19o. SEX Male ' Arlington ... ., Tarrant Texas ~ I ;oF• I I :':. GR.tu "v1-i DANIEL WADE N 20b. DATE OF BIRTH 20c. sex 20d.l '(CITY. t g 08/03/2009 Male J'l.HUI!\IUII Tarrant Texas 20e.l ' I 21 a. CHILD CURRENT RHYDER COLE WADE .., 21b. OATEOFetRTH I 210. SEX 21d. BIRTHPlACE (CITY, (X)I.JNTY AND STATE} 9 ,_. v 08118/2011 Male Arlington Tarrant Texas 'u 21e.1 .... ...-~~ ~~-- _"""·~·--· I CERTIFY THAT THE ABOVE ORDER WAS GRANTED ON THE DATE AND '~-_; CftVJIUf SIGNATURE OF THE CLERK OF THE COURT WARNING: This Is a governmental document. Texas Penal Code, Section 37.10, specines penalties for making false entries or providing false information in this document VS-165 REV 0712015 Texas Department of State Heahh Services- Vital Statistics VS-165 REV 0712015 1 __ .,, ,,,_,.. _,, •• r-'00. --·-- -· .. ...._ ,,,_ --··. ''"-'" ... --··-· .. - ~ -- 23a. CHILD CURRENT tw.4E {FIRST MIDDLE LAST SUFFIX) "'~ 23b. DATE Of BIRTH (rnm'dd)':r»} T23c.SEX 123d. BIRTH'I.ACE {CITY, CCXNTY AND STATE) •u 23e. PRIOR NAME OF CHILD (FIRST lrfDDt.E LAST SUFFix) -IF APPUCABLE f 24a. CHILD CURRENT NAME (FIRST MIDDLE LAST SUFFix) "'9 2<4b. DATE Of BIRTH (mm'dCVy)')y) T24c.SEX I 24d. BIRTHPLACE (cnv,_cotJNTl' AND STArE) • u 248. PRIOR NAME OF O"tiLO {FIRST MionE LAST SUFFix) -IF APPLICABLE 25a. CHILD CURRENT KAME (FIRST lrfiOCU LAST SUFFix) c 25b. DATE Of BIRTH (fTVTII'ddlyyyy) 125c.SEX -r 25d. BIRTt-FLACE {CITY, COUNTY AND STATE) g 25e. PRIOR NAME Of CHILO (FIRST MIDDLE LAST SUFFIX) -IF APPUCABLE ' Instructions for Completing the Suit Affecting Parent Child Relationship Form GENERAL REQUIREMENT: All divorces/annulments (with or without children) and all suits affecting the parent-child relationship must be reported through the clerk ofthe court to the State Vrtal Statistics Un~ (VSU). Consolidated reporting by petitioners, attorneys, and the courts is designed to make mandatory reporting more efficient, timely, and Improve the quality of reporting. However, this reporting system is only as good or timely as you make It: therefore, your attention in completing and filing this report is critical. legal basis for this reporting is contained in Heanh and Safety Code §194.002 and Texas Family Code §§108.001-.002 and 108.004. For infonnation concerning reporting or questions about this form, contact field services at fieldservices@dshs.texas.gov or by phone at 512- 776-7368. For information on the court of continuing jurisdiction of a child, contact VSU at {888) 96~7111 ext. 2529. Inquiries should be addressed to VSU, 1100 West 49"' Street, Austin, Texas. 78756-Jt 9t; inquiries may also be faxed to (5t2) 456-n83. SECTION 1 GENERAL INFORMATION (REQUIRED) This section must be completed for each report filed. • 1a- d. Enter the required Information to identify the court proceeding. • 2. Check the type of suit being reported. This determines also which sections ofthe form must be completed. If more than one type of order applies, check aU that apply. Transfers from one jurisdidion to another must be reported in this section (if court number is unknown, specify •unknown~). • 3a- c. Complete the attorney Information to assist In questions or follow up. If case was prose. p4ease enter the lnfonnatlon of the person completing this form. SECTION 2 (IF APPUCABLE) REPORT OF DIVORCE OR ANNULMENT OF MARRIAGE All divorces/annulments must be reported, even if there were no minor children. AU information is required. • 4-9. Report the Petitioner's information Including maiden nama {if applicable). • 10-15. Report the Respondent's information, including maiden name (if applicable). • 16. Report the number of minor children affected by this divorce; if none, record "O: This number must correspond to the listing of children in Section 3. • 17-18. Enter the date and place of the marriage being dissolved. SECTION 3 (IF APPUCABLE) CHILDREN AFFECTED BY THIS SUIT Every child affected by the suit being reported must be listed, and all items concerning that child must be completed. If more than three children are affected, check the "additional children listed on back of fonn· box, and continue to list the additional children. If more than 6 children complete section 3 on another form, label it "continuation• and attached the continuation fonn to the original form. Texas Department ol State Health Services- VItal Statistics VS·165 REV 0712015 2