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Connecticut Dissolution of Marriage Report Form


Connecticut Dissolution of Marriage Report Form
Connecticut Dissolution of Marriage Report Form
Type of Decree
Case Contested
Decree Granted To
Yes
Divorce
Plaintiff
Custody of Minor Children To
Public Assistance Recipient — Cash Recipient
CSSD Family Services Evaluation CSSD Family Services Mediation
Yes No
Attorney For minor Child(ren) Guardian Ad Litem For Minor Child(ren)
DISSOLUTION OF MARRIAGE
REPORT
STATE OF CONNECTICUT
SUPERIOR COURT
JD-FM-181 Rev. 11-09
P.B. § 25-58
1. To be completed by the Attorney for the Plaintiff or, if a
Self-Represented Person, by the Plaintiff.
2. Clerk to complete section 2.
Plaintiff
Signed (Clerk or Assistant Clerk)
PART 1 (To be completed by the Attorney for the Plaintiff or if a Self-Represented Person, by the Plaintiff)
Instructions
Usual Residence (Number and street) City or Town
Zip codeState Birthplace (State or Foreign Country)
Defendant
Name (First, middle, last)
Usual Residence (Number and street) City or town
Zip code
State Birthplace (State or Foreign Country)
Marital History
Place of This Marriage (City) State
Approximate Date Couple Separated (Month, Year)Date of Marriage (Month, Day, Year)
Number of Children Born Alive of This Marriage Number of Children Still Living Number of Children Under 18
Years of Age
Yes
No
Yes No
Attorney For Plaintiff (If Applicable) (Name) Attorney's Address (If Applicable) (Number street, city, state, zip code)
Information For Statistical Purposes Only:
(To be completed by the Attorney for the Plaintiff or, if a Self-Represented Person, by the Plaintiff)
Date of Decree (Month, Day, Year)
Annulment
Date Writ Returnable (Month, Year)
Legal Grounds for Dissolution (Specify)
No Plaintiff Defendant
Number of This
Marriage (First,
Second, etc. specify)
For Defendant
If Previously Married,
How Many Ended By
Death
Divorce or
Annulment
For Plaintiff For Plaintiff
For Defendant
For Plaintiff
For Defendant
Education - Specify Highest Grade Completed
Elementary
(0,1,2,3, thru 8)
High School
(1,2,3, or 4)
College
(1,2,3, 4 or 5+)
Plaintiff
Defendant
Plaintiff
Defendant
Plaintiff
Defendant
PART 2 (To be completed by the Clerk of Superior Court)
Decree
Defendant
Title of Official
Joint Not Applicable
Docket Number
FA
www.jud.ct.gov
Yes No
Yes No
Name (First, middle, last)
Zip code
Number of Children Under 23
Years of Age
Conflict Resolution Conference
Yes No
Issue Focused Evaluation
Yes No
Public Assistance Recipient — HUSKY
Recipient (Medical)
Yes No
Date of civil union that merged into marriage
by subsequent ceremony or by
operation of law (Month, Day, Year)
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Connecticut Dissolution of Marriage Report Form