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Connecticut Dissolution of Marriage Report Form

In order to divide debts and assets of a dissolved marriage in the State of Connecticut, the following form has to be used.

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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) :
Next: Colorado Durable General Power of Attorney Form Previous: Consent and Waiver by Parents
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