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Connecticut Dissolution Agreement Form


Connecticut Dissolution Agreement Form
Connecticut Dissolution Agreement Form
1. Our ("X" one)
DISSOLUTION AGREEMENT
STATE OF CONNECTICUT
SUPERIOR COURT
JD-FM-172 Rev. 7-10
C.G.S. ยงยง 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*
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Connecticut Dissolution Agreement Form
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