Connecticut Dissolution Agreement Form
In the case of reaching an agreement regarding dividing the assets of a dissolved marriage in the State of Connecticut, the following form has to be completed and submitted.
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1. Our ("X" one) DISSOLUTION AGREEMENT STATE OF CONNECTICUTSUPERIOR 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 c\ hild(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 t\ he 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 b\ y immediate income withholding unless for cause or we both agree to it being contingent: We agree to a (n) Immediate Contingentincome 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 or former name of . Defendant's name is restored to the birthname of or former name of . 13. Other: Plaintiff (Print name) Defendant (Print name) Plaintiff's signature Defendant's signature Date signed 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 t\ he parents would have provided post-majority educational support, and for the Court to reserve jurisdiction to determ\ ine 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) :
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