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INFORMATION ON SUIT AFFECTING THE FAMILY RELATIONSHIP
(EXCLUDING ADOPTIONS)
SECTION I GENERAL INFORMATION (REQUIRED) STATE FILE NUMBER
,a. couNTY -----------
Tarrant 1b. COURT NO. 360th
----------
1c. CAUSE NO. 360-647689-18 1d. DATE OF ORDER (mm/dd/yyyy)05/28/19
2. TYPE OF ORDER (CHECK ALL THAT APPLY):
• DIVORCE/ANNULMENT lMilJ CHILDREN (Sec. 1, 2 AND 3) DIVORCE/ANNULMENTWlTHOUT CHILDREN (Sec 1 AND 2)
ESTABLISHMENT OF COURT OF CONTINUING JURISDICTION (SEC 1 AND 3)
(Court Order Establishing Patemify, Conservatorship, Chile! 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 ATTORNEY FOR PETITIONER
DWavne Smith
I(817) 737-4000
3b. TELEPHONE NUMBER (indud,ng area code)
3C. CURRENT MAILING ADDRESS (STREET AND NUMBER OR P.O BOX, CITY, STATE, ZIP)
3821 Camp Bowie Blvd., Fort Worth, Texas 76107
SECTION 2 (IF APPLICABLE) REPORT OF DIVORCE OR ANNULMENT OF MARRIAGE
4. NAME (FIRST MJDDLE LAST SUFFIX) 5. MAIDEN LAST NAME {NAME BEFORE 1" MARRIAGE)
,r
w Christina Becker Romeo
z
0 6. PLACE OF BIRTH (CITY AND STA TE OR FOREIGN COUNTRY) 17. RACE (mm/dd/yyyy)
8. DATE OF BIRTH
~w Fort Worth, Texas Caucasian 12/25/1981
9. USUAL RESIDENCE STREET NAME & NUMBER c,ry z,p
a. STATE
12265 Indian Creek Dr. Fort Worth, Texas 76179
10. NAME (FIRST MIDDLE LAST SUFFIX} 11. MAIDEN LAST NAME (/\/AME BEFORE 1"' MARRIAGE)
I-
z
w
Reed Becker
•z 12. PLACE OF BIRTH (CITY AND STATE OR FOREIGN COUNTRY) 113. RACE 14. DATE OF BIRTH (mm/dd/yyyy)
0
a. Winnipeg, MB,CA Caucasian 06/03/1976
"'
w 15. USUAL RESIDENCE (STREET AND NUMBER CITY, STATE, ZIP)
"' 8942 Heron Nest Dr. Houston, Texas 77064
I ~74i23ii(t1~mmldcLyyyy)
16. NiBER OF MINOR CHILDREN
118. Pl.ACE OF MARRIAGE (CITY AND STATE OR FORE!GN COUNTRY)
Austin Texas
SECTION 3 (IF APPLICABLE) CHILDREN AFFECTED BY THIS SUIT
19a. CHILD CURRENT NAME (FIRST M!DDLE LAST SUFFIX)
Rhett Romeo Becker
-
9
(mmlddlym)
19b. DATE OF BIRTH
11/11/2016 IM~i; IB~·;J/~7:;'CACOUNTYANDSTATE)
'
0
19e. PRIOR NAME OF CHILD (FIRST MIDDLE LAST SUFFIX) -
IF APPLICABLE
20a. CHILD CURRENT NAME (FIRST MIDDLE LAST SUFFIX)
N (mmlddlyyyy)
20b. DATE OF BIRTH I20c. SEX I 20d. BIRTHPLACE (CITY, COUNTY AND STA TE)
~
u
20e. PRIOR NAME OF CHILO (FIRST M!DDLE LAST SUFFIX)- IF APPi.lCABLE
21a. CHILD CURRENT NAME. (FIRST MIDDLE LAST SUFFIX)
M
~
(mmlddlyyyy)
21b. DATE OF BIRTH I21C. SEX I 21d. BIRTHPLACE {CITY, COUNTY AND STATE)
r
0
21e. PRIOR NAME OF CHILO {FIRST MIDDLE LAST SUFFIX:)- IF APPI..JCABLE
I AOOITIONALCHILDREN LISTED ON BACK OF THIS FORM.
-········~3.,.?;\-. .:,rJl
.ts··,.,
i , \ ~ ~._
•••"()'(
f r
I CERTIFY THAT THE ABOVE ORDER WAS GRANTED ON THE DATE AND PLAC{~
.-rrx::i
ifj"t;.~\' 'i,_ ", '.Jl 'Lr ½ /1 ),11~
t
~\ ~ ·~J/-.f'\
.,.,_.,,.,.,.~.jSIGNAtURE OF !)ft- CLERK OF THE COURT
·•-.'<'J>,,·,,,~,.
-..c,'Y_l
WARNING: This is a governmental document.Texas Penal Code, sefyb~-~;..,s·pecifies penalties for making false
entries or providing false information in this document.
VS-165 REV 07i':zotr····
Texas Department of State Health Services - Vital Statistics VS-165 REV 07/2017
1
Preview
INFORMATION ON SUIT AFFECTING THE FAMILY RELATIONSHIP (EXCLUDING ADOPTIONS) SECTION I GENERAL INFORMATION (REQUIRED) STATE FILE NUMBER ,a. couNTY ----------- Tarrant 1b. COURT NO. 360th ---------- 1c. CAUSE NO. 360-647689-18 1d. DATE OF ORDER (mm/dd/yyyy)05/28/19 2. TYPE OF ORDER (CHECK ALL THAT APPLY): • DIVORCE/ANNULMENT lMilJ CHILDREN (Sec. 1, 2 AND 3) DIVORCE/ANNULMENTWlTHOUT CHILDREN (Sec 1 AND 2) ESTABLISHMENT OF COURT OF CONTINUING JURISDICTION (SEC 1 AND 3) (Court Order Establishing Patemify, Conservatorship, Chile! 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 ATTORNEY FOR PETITIONER DWavne Smith I(817) 737-4000 3b. TELEPHONE NUMBER (indud,ng area code) 3C. CURRENT MAILING ADDRESS (STREET AND NUMBER OR P.O BOX, CITY, STATE, ZIP) 3821 Camp Bowie Blvd., Fort Worth, Texas 76107 SECTION 2 (IF APPLICABLE) REPORT OF DIVORCE OR ANNULMENT OF MARRIAGE 4. NAME (FIRST MJDDLE LAST SUFFIX) 5. MAIDEN LAST NAME {NAME BEFORE 1" MARRIAGE) ,r w Christina Becker Romeo z 0 6. PLACE OF BIRTH (CITY AND STA TE OR FOREIGN COUNTRY) 17. RACE (mm/dd/yyyy) 8. DATE OF BIRTH ~w Fort Worth, Texas Caucasian 12/25/1981 9. USUAL RESIDENCE STREET NAME & NUMBER c,ry z,p a. STATE 12265 Indian Creek Dr. Fort Worth, Texas 76179 10. NAME (FIRST MIDDLE LAST SUFFIX} 11. MAIDEN LAST NAME (/\/AME BEFORE 1"' MARRIAGE) I- z w Reed Becker •z 12. PLACE OF BIRTH (CITY AND STATE OR FOREIGN COUNTRY) 113. RACE 14. DATE OF BIRTH (mm/dd/yyyy) 0 a. Winnipeg, MB,CA Caucasian 06/03/1976 "' w 15. USUAL RESIDENCE (STREET AND NUMBER CITY, STATE, ZIP) "' 8942 Heron Nest Dr. Houston, Texas 77064 I ~74i23ii(t1~mmldcLyyyy) 16. NiBER OF MINOR CHILDREN 118. Pl.ACE OF MARRIAGE (CITY AND STATE OR FORE!GN COUNTRY) Austin Texas SECTION 3 (IF APPLICABLE) CHILDREN AFFECTED BY THIS SUIT 19a. CHILD CURRENT NAME (FIRST M!DDLE LAST SUFFIX) Rhett Romeo Becker - 9 (mmlddlym) 19b. DATE OF BIRTH 11/11/2016 IM~i; IB~·;J/~7:;'CACOUNTYANDSTATE) ' 0 19e. PRIOR NAME OF CHILD (FIRST MIDDLE LAST SUFFIX) - IF APPLICABLE 20a. CHILD CURRENT NAME (FIRST MIDDLE LAST SUFFIX) N (mmlddlyyyy) 20b. DATE OF BIRTH I20c. SEX I 20d. BIRTHPLACE (CITY, COUNTY AND STA TE) ~ u 20e. PRIOR NAME OF CHILO (FIRST M!DDLE LAST SUFFIX)- IF APPi.lCABLE 21a. CHILD CURRENT NAME. (FIRST MIDDLE LAST SUFFIX) M ~ (mmlddlyyyy) 21b. DATE OF BIRTH I21C. SEX I 21d. BIRTHPLACE {CITY, COUNTY AND STATE) r 0 21e. PRIOR NAME OF CHILO {FIRST MIDDLE LAST SUFFIX:)- IF APPI..JCABLE I AOOITIONALCHILDREN LISTED ON BACK OF THIS FORM. -········~3.,.?;\-. .:,rJl .ts··,., i , \ ~ ~._ •••"()'( f r I CERTIFY THAT THE ABOVE ORDER WAS GRANTED ON THE DATE AND PLAC{~ .-rrx::i ifj"t;.~\' 'i,_ ", '.Jl 'Lr ½ /1 ),11~ t ~\ ~ ·~J/-.f'\ .,.,_.,,.,.,.~.jSIGNAtURE OF !)ft- CLERK OF THE COURT ·•-.'<'J>,,·,,,~,. -..c,'Y_l WARNING: This is a governmental document.Texas Penal Code, sefyb~-~;..,s·pecifies penalties for making false entries or providing false information in this document. VS-165 REV 07i':zotr···· Texas Department of State Health Services - Vital Statistics VS-165 REV 07/2017 1