BETH DIN ZEDEK  BETH DIN ZEDEK ECCLESIASTICAL JUDICATURE OF THE  CHICAGO RABBINICAL COUNCIL W. Howard Street ◌ּ Chicago, Illinois 60645-1303 2701 773-465-3900 FAX: 773-465-6632 e-mail:[email protected] 

  RABBI ISRAEL M. KARNO RABBI GEDALIA DOV SCHWARTZ Av Beth Din Emeritus Av Beth Din DIVORCE RECORD   RABBI C. DAVID REGENSBERG, of blessed memory RABBI ALAN M. ABRAMSON HUSBAND WIFE

English Name: ______English Name: ______Last First Middle Maiden First Middle Hebrew Name: ______son of ______Hebrew Name: ______daughter of ______Kohen / Levi / Israelite (please circle) Address: ______Address: ______Contact Information: Contact Information: Home: ______Work: ______Home: ______Work: ______Cell: ______E‐mail: ______Cell: ______E‐mail: ______Will you resume your maiden name? □ Yes □ No Adopted/converted? _____ Parents adopted/converted? _____ Adopted/converted? ____ Parents adopted/converted? _____ If you and/or your parents were adopted or converted, please indicate If you and/or your parents were adopted or converted, please indicate whom and attach a copy of all conversion papers to this application. whom and attach a copy of all conversion papers to this application. Previously married? ______If so, how did the previous Previously married? ______If so, how did the previous marriage terminate? ______(e.g. death, divorce, etc.) marriage terminate? ______(e.g. death, divorce, etc.) If previously divorced, provide the name of the Rabbinic Court If previously divorced, provide the name of the Rabbinic Court that issued the Get: ______and that issued the Get: ______and attach a copy of your previous Get document. attach a copy of your previous Get document.

Marriage ______Date City Officiating Rabbi

Separated as of ______

Civil Divorce ______State County City Date of Final Decree Index No.

Suggested Dates/Times (i.e. Mondays, afternoons, April 12th) When You are Available for Your Get:*

1. ______2. ______3. ______

*Please note that we generally schedule appointments in the afternoons Monday through Thursday. *Modest Attire Requested*

FOR OFFICE USE ONLY Fee Date Scheduled File No.

Name of Mesader HaGet Name of Sofer:

Other Members of Beth Din:

Witnesses:

Hebrew Date: Date Get Issued:

If delivery via Shaliach: Location of Get Delivery

Name of Shaliach

A non‐refundable deposit of $150 is due with this application.