Civil Union Dissolution Form

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

• Complete and print the application below.
• Sign and date the application.
• Make check or money order payable to "Vermont Department of Health".
• The fee for certified copies is $10.00 per copy.
• Return the application with your check or money order to the address below. Do NOT mail cash.

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

For more information visit: Obtaining Vital Records

Application for a Certified Copy of a Record of Civil Union Dissolution

For office use only ID# CPA# REC#

Number of Copies:
Amount Enclosed $
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