NAME
DATE
ARKANSAS DEPARTMENT OF HEALTH
Vital Records, Slot 44
4815 West Markham
Little Rock, AR 72205
DIVORCE COUPON 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.
Divorce records
can be requested online, by telephone, by mail, or in-person.
If no record is found, $10.00 will be kept to cover the search charge.
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
What is your relationship to the parties named on the requested record?
What is your reason for requesting a copy of this record?
Signature and Telephone Number of Person Requesting this Certificate
X
Please PRINT the name and address of
the person receiving this request on
the
lines below.
ADDRESS
STATE
ZIP
Certificates may be ordered by the following methods:
(All requests require identity verification)
Internet: ar.gov/vitalrecords A $5.00 non-refundable processing fee and a $1.85
identification verification fee will be charged in addition to any expedited shipping options
selected. Fees can be paid by debit or credit card (VISA, Mastercard, Discover, or
American Express). Requests typically take 7 - 14 business days from the date your order
is approved plus shipping time.
Telephone: Toll free (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.
Mail: Mail this application, a copy of your photo ID, and your check or money order to:
Arkansas Department of Health
Vital Records Section-Slot 44
4815 West Markham Street
Little Rock, AR 72205
The fee must be sent along with the application. Make the check or money order payable
to the Arkansas Department of Health. DO NOT SEND CASH. Please allow 7-14 days for
processing by mail.
Walk-in: Bring your photo ID and this completed application to the office. Orders are
accepted for same day issuance from 8:00 A.M. until 4:00 P.M. Monday through Friday.
The office is located at 4815 West Markham St. Little Rock, AR 72205.
Please order family history and genealogy by mail or online.
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 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).
VR-10 (R 8/11)
CERTIFIED COPIES
Each copy is $10.00.
HOW MANY _______
AMOUNT OF MONEY ENCLOSED
$__________
CITY
