Connecticut > Statewide > Family
Dissolution Agreement JD-FM-172 - Connecticut
| Dissolution Agreement Form. This is a Connecticut form and can be used in Family Statewide . |
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DISSOLUTION AGREEMENT JD-FM-172 Rev. 2-07 C.G.S. ยงยง 46b-51, 46b-38oo STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov AT (Town) DOCKET NO. DEFENDANT'S NAME (Last, first, middle initial) COURT USE ONLY AGREMNT JUDICIAL DISTRICT OF PLAINTIFF'S NAME (Last, first, middle initial) The plaintiff and defendant agree that: 1. Our ("X" one) marriage civil union 2. The custody of the child(ren) shall be as follows: Legal Custody: Primary Residence: 3. As to visitation with the child(ren): has broken down irretrievably. Who will pick up/drop off for visits: Holiday and school vacation visits: The amounts / percentages indicated below for child support, health insurance and unreimbursed medical costs, and child care costs must agree with the Child Support and Arrearage Guidelines (available at Clerk's Office) unless you meet one of the deviation criteria listed in the Guidelines. 4. As to current and/or past due child support: Agrees with Child Support and Arrearage Guidelines Does not agree (give reason for deviation) Do not know 5. As to health insurance and unreimbursed medical costs: Agrees with Child Support and Arrearage Guidelines 6. As to child care costs: Does not agree (give reason for deviation) Do not know Agrees with Child Support and Arrearage Guidelines Does not agree (give reason for deviation) (Continued...) Do not know American LegalNet, Inc. www.FormsWorkflow.com 7. As to educational support: Either parent may file a motion or petition for an educational support order at a subsequent date. We each waive the right to file a motion or petition for an educational support order. 8. As to alimony: 9. As to income withholding: 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 change of name: 13. Other: We certify that the above statements are our agreement. PLAINTIFF (Print name) DEFENDANT (Print name) PLAINTIFF'S SIGNATURE DEFENDANT'S SIGNATURE DATE SIGNED DATE SIGNED JD-FM-172 (Back) Rev. 2-07 American LegalNet, Inc. www.FormsWorkflow.com
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