Fillable Printable Dissolution Agreement of Marriage - Connecticut

Dissolution Agreement of Marriage - Connecticut

1. Our ("X" one)

DISSOLUTION AGREEMENT

STATE OF CONNECTICUT

SUPERIOR COURT

JD-FM-172 Rev. 7-10

C.G.S. §§ 46b-51, 46b-38oo

and

The plaintiff and defendant agree that:

www.jud.ct.gov

2. The custody of the child(ren) shall be as follows:

Court Use Only

AGREMNT

Judicial District of

At (Town)

Docket number

Plaintiff's name (Last, first middle initial) Defendant's name (Last, first, middle initial)

Instructions: The instructions for filling out this form are on form JD-FM-172A.

marriage civil union has broken down irretrievably.

Joint legal custody to

Primary residence with:

Sole custody to:

A parenting responsibility plan in the best interest(s) of the minor child(ren)

3. As to visitation with the child(ren):

Who will pick up/drop off for visits or parenting time transition:

Holiday and school vacation schedule:

The amounts/percentages indicated below for Child Support, Health Care Insurance Coverage and Unreimbursed

Health Care Costs, and Child Care Costs must follow the Child Support and Arrearage Guidelines (the Guidelines), which

are available at Clerk's Offices and on the Judicial Branch website at www.jud.ct.gov/publications, unless you ask for one of

the deviation criteria to apply (reasons for an amount different than the Guidelines).

4. As to current and/or past due Child Support:

This amount follows the Guidelines.

5. As to the child's or children's required Health Care Insurance Coverage and Unreimbursed Health Care Costs:

This amount follows the Guidelines.

(Continued on back/next page)

shall be incorporated by reference or

as follows:

This amount is different from the Guidelines (deviation). Give reason for deviation from the Guidelines (see

Guidelines for reason that applies):

This amount is different from the Guidelines (deviation). Give reason for deviation from the Guidelines (see

Guidelines for reason that applies):

*AGREMNT*

JD-FM-172 (Back) Rev. 7-10

6. As to Child Care Costs that qualify under the Guidelines:

This amount follows the Guidelines.

7. As to post-majority educational support ("x" one):

8. As to alimony:

9. As to income withholding, we understand that the support orders are by immediate income withholding unless for cause

or we both agree to it being contingent: We agree to a(n)

Immediate Contingent

income withholding.

10. As to division of property:

As to real property

As to personal property

11. As to division of debts:

12. As to the change of name:

Plaintiff's name is restored to the birthname of

former name of

Defendant's name is restored to the birthname of

former name of

13. Other:

Plaintiff (Print name)

Defendant (Print name)

Plaintiff's signature

Defendant's signature

Date signed

We certify that the above statements are our agreement.

Both of the parties have made a knowing and intelligent waiver of their right to request a post-majority educational

support order; or

The parties ask the Court to reserve jurisdiction to determine whether a post-majority educational support order

should issue and the terms of the order; or

The parties ask the Court to find that it is more likely than not that the parents would have provided post-majority

educational support, and for the Court to reserve jurisdiction to determine whether to enter an educational support

order and the terms of the order; or

The parties ask the Court to enter a post-majority education support as follows (Attach additional sheets if

necessary):

This amount is different from the Guidelines (deviation). Give reason for deviation from the Guidelines (see

Guidelines for reason that applies):