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Certification of Public Assistance Form

If you are applying for a divorce in the State of Connecticut and wish to inform the state of this divorce application, you have to use the following form. Complete the form and send it along with any required filing fees.

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If any party or any child received public assistance from the State of Connecticut:The Office of the Attorney General
55 Elm Street
Hartford, CT 06106
If any party or any child received public assistance from any town or city
in the State of Connecticut:
The City Clerk for the town providing public assistance:	
JUDICIAL DISTRICT OF	AT  (Town)	
DOCKET NO.  (If known)	
CERTIFICATION OF NOTICE
IN FAMILY CASES
(PUBLIC ASSISTANCE)
JD-FM-175 Rev. 1-2001
P.B. §§ 10-12 through 10-17,
25-2
C.G.S. § 46b-55
SIGNATURE
And State Marshal's return was mailed/delivered on  (month, day, year)
NAME OF CASE	
RETURN DATE (Mo., day, year) (if applicable)	
(No., street, town)	
ADDRESS (No., street, town, state, zip code)	
CERTPA	
COURT USE ONLY	
TELEPHONE NO.  (Area code first)	
INSTRUCTIONS	
(CHECK ALL THAT APPLY)
This is to certify that a true copy of the:
Summons
Complaint
Custody Application  (only if seeking child support)
Notice of Automatic Court Orders
Order to Attend Hearing  (for custody actions seeking support)
Affidavit Concerning Children  (for proceedings seeking custody)
Financial Affidavit 	
to:	
If you, your spouse, or your children have ever received public assistance (state aid, city aid, or
welfare) follow the instructions below (visitation actions are exempt from these requirements): 
1. Mail or deliver a copy of the Summons and Complaint or Custody Application, Notice of 
      Automatic Court Orders, Order to Attend Hearing (if applicable), and a copy of the State Marshal's 
   return (proof that the court papers were served) to the Attorney General or Town Clerk's office. 

2. Complete the form below. 
3. Keep a copy for your records.
4. File this Certification form with the court clerk when you file your Summons and Complaint 
      	
 or Custody Application.	
   www.jud.ct.gov
STATE OF CONNECTICUT
SUPERIOR COURT	
PRINT NAME
Next: Child-Support-Obligation Income Statement and Affidavit Previous: California Judgment Form
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