Civil Union Dissolution Form

To order a civil union dissolution certificate from the Department of Health:

• Complete the application below
• Print it on your local printer.
• Sign and date the application
• Return it with your check or money order to the address below.
  Make checks or money orders payable to: Vermont Department of Health. Do NOT mail cash.

Send to:
Vermont Department of Health
Vital Records
P.O. Box 70
Burlington, VT 05402-0070

Fees:
Certified copy: $10.00
Verification: no charge
Record Search: no charge

For more information visit: Obtaining Vital Records

Application for Vital Record Record of Civil Union Dissolution

For office use only ID# CPA# REC#

Request for:

Certified Copy Verification Record Search

Name of PARTY A :
Name of PARTY B :
Date dissolution became final :
County of dissolution :
Date of Civil Union:

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Your Name :
Address:
Town:
State:
Zip:
Phone Number:
Your Relationship to people named on the certificate

Intended use of certificate

Proof of Dissolution Personal Use Other: (specify)

Date: _____________________________

Signature: _____________________________________________________________________

Send to: Vermont Department of Health, Vital Records, PO Box 70, Burlington, VT 05402-0070