Austin Report (BVS-165)


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INFORMATION ON SUIT AFFECTING THE FAMILY RELATIONSHIP 
(EXCLUDING ADOPTIONS) 
SECTION I  GENERAL INFORMATION (REQUIRED)  STATE FILE NUMBER 
1a. COUNTY __________________________ 1b. COURT NO. ________________________ 
1c. CAUSE NO. ________________________ 1d. DATE OF ORDER (mm/dd/yyyy) _________ 
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) 
⃞ ESTABLISHMENT 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 ATTORNEY FOR PETITIONER 3b. TELEPHONE NUMBER (including area code)
3c. CURRENT MAILING ADDRESS (STREET AND NUMBER OR P.O BOX, CITY, STATE, ZIP)
SECTION 2 (IF APPLICABLE) REPORT OF DIVORCE OR ANNULMENT OF MARRIAGE
P
E
TI
TI
O
N
ER
 
4. NAME (FIRST MIDDLE LAST SUFFIX) 5. MAIDEN LAST NAME (NAME BEFORE 1ST MARRIAGE) 
6. PLACE OF BIRTH (CITY AND STATE OR FOREIGN COUNTRY) 7. RACE 8. DATE OF BIRTH (mm/dd/yyyy)
9. USUAL RESIDENCE STREET NAME & NUMBER   CITY   STATE  ZIP
R
E
S
PO
N
D
EN
T 
10. NAME (FIRST MIDDLE LAST SUFFIX) 11. MAIDEN LAST NAME (NAME BEFORE 1ST MARRIAGE) 
12. PLACE OF BIRTH (CITY AND STATE OR FOREIGN COUNTRY) 13. RACE 14. DATE OF BIRTH (mm/dd/yyyy)
15. USUAL RESIDENCE (STREET AND NUMBER CITY, STATE, ZIP)
16. NUMBER OF MINOR CHILDREN 17. DATE OF MARRIAGE (mm/dd/yyyy) 18. PLACE OF MARRIAGE (CITY AND STATE OR FOREIGN COUNTRY) 
SECTION 3 (IF APPLICABLE) CHILDREN AFFECTED BY THIS SUIT
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19a. CHILD CURRENT NAME (FIRST MIDDLE LAST SUFFIX) 
19b. DATE OF BIRTH (mm/dd/yyyy) 19c. SEX 19d. BIRTHPLACE (CITY, COUNTY AND STATE)
19e. PRIOR NAME OF CHILD (FIRST MIDDLE LAST SUFFIX) – IF APPLICABLE
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IL
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20a. CHILD CURRENT NAME (FIRST MIDDLE LAST SUFFIX)
20b. DATE OF BIRTH (mm/dd/yyyy) 20c. SEX 20d. BIRTHPLACE (CITY, COUNTY AND STATE)
20e. PRIOR NAME OF CHILD (FIRST MIDDLE LAST SUFFIX) – IF APPLICABLE
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H
IL
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21a. CHILD CURRENT NAME (FIRST MIDDLE LAST SUFFIX)
21b. DATE OF BIRTH (mm/dd/yyyy) 21c. SEX 21d. BIRTHPLACE (CITY, COUNTY AND STATE)
21e. PRIOR NAME OF CHILD (FIRST MIDDLE LAST SUFFIX) – IF APPLICABLE
ഽ ADDITIONAL CHILDREN LISTED ON BACK OF THE FORM. 
I CERTIFY THAT THE ABOVE ORDER WAS GRANTED ON THE DATE AND PLACE AS STATED. _____________________________________ 
  SIGNATURE OF THE CLERK OF THE COURT 
WARNING: This is a governmental document.  Texas Penal Code, Section 37.10, specifies penalties for making false 
entries or providing false information in this document.  VS-165  REV 07/2017
Texas Department of State Health Services - Vital Statistics  VS-165 REV 07/2017 1 
  
 
    
    
 
    
    
 
    
    
 
 
 
 
 
 
 
ADDITIONAL CHILDREN AFFECTED BY THIS SUIT FROM SECTION 3 (IF APPLICABLE) 
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23a. CHILD CURRENT NAME (FIRST MIDDLE LAST SUFFIX) 
23b. DATE OF BIRTH (mm/dd/yyyy) 23c. SEX 23d. BIRTHPLACE (CITY, COUNTY AND STATE)
23e. PRIOR NAME OF CHILD (FIRST MIDDLE LAST SUFFIX) – IF APPLICABLE
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IL
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24a. CHILD CURRENT NAME (FIRST MIDDLE LAST SUFFIX)
24b. DATE OF BIRTH (mm/dd/yyyy) 24c. SEX 24d. BIRTHPLACE (CITY, COUNTY AND STATE)
24e. PRIOR NAME OF CHILD (FIRST MIDDLE LAST SUFFIX) – IF APPLICABLE
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25a. CHILD CURRENT NAME (FIRST MIDDLE LAST SUFFIX)
25b. DATE OF BIRTH (mm/dd/yyyy) 25c. SEX 25d. BIRTHPLACE (CITY, COUNTY AND STATE)
25e. PRIOR NAME OF CHILD (FIRST MIDDLE LAST SUFFIX) – IF APPLICABLE
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 of the 
court to the State Vital Statistics Unit (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 Health and Safety Code §194.002 and Texas Family Code §§108.001-.002 and 108.004. 
For information concerning reporting or questions about this form, contact field services at fieldservices@dshs.texas.gov or by phone at 512- 
776-3010.
 
The VSU-165 form must be printed double-sided (one sheet not two). 
For information on the court of continuing jurisdiction of a child, contact VSU at (888) 963-7111 ext. 2529. Inquiries should be addressed to 
VSU, 1100 West 49th Street, Austin, Texas, 78756-3191; inquiries may also be faxed to (512) 776-7164 .
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 of the form must be completed. If more than one type of 
order applies, check all that apply. Transfers from one jurisdiction 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 pro se, please enter the information of the
person completing this form.
SECTION 2 (IF APPLICABLE)     REPORT OF DIVORCE OR ANNULMENT OF MARRIAGE
All divorces/annulments must be reported, even if there were no minor children. All information is required.
  
 4-9. Report the Petitioner’s information including maiden name (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 “0.” 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 APPLICABLE)     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 form” 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 form to the original form. 
Texas Department of State Health Services - Vital Statistics  	 VS-165 REV 07/2017 2