Free DISSOLUTION AGREEMENT - Connecticut

DISSOLUTION AGREEMENT
JD-FM-172 Rev. 2-07 C.G.S. §§ 46b-51, 46b-38oo

STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov
AT (Town) DOCKET NO. DEFENDANT'S NAME (Last, first, middle initial)

COURT USE ONLY

AGREMNT

JUDICIAL DISTRICT OF PLAINTIFF'S NAME (Last, first, middle initial)

The plaintiff and defendant agree that: 1. Our ("X" one) marriage civil union 2. The custody of the child(ren) shall be as follows: Legal Custody: has broken down irretrievably.

Primary Residence: 3. As to visitation with the child(ren):

Who will pick up/drop off for visits: Holiday and school vacation visits:

The amounts / percentages indicated below for child support, health insurance and unreimbursed medical costs, and child care costs must agree with the Child Support and Arrearage Guidelines (available at Clerk's Office) unless you meet one of the deviation criteria listed in the Guidelines. 4. As to current and/or past due child support:

Agrees with Child Support and Arrearage Guidelines

Does not agree (give reason for deviation)

Do not know

5. As to health insurance and unreimbursed medical costs:

Agrees with Child Support and Arrearage Guidelines 6. As to child care costs:

Does not agree (give reason for deviation)

Do not know

Agrees with Child Support and Arrearage Guidelines

Does not agree (give reason for deviation)
(Continued...)

Do not know

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7. As to educational support:

Either parent may file a motion or petition for an educational support order at a subsequent date. We each waive the right to file a motion or petition for an educational support order. 8. As to alimony:

9. As to income withholding: We agree to a(n) IMMEDIATE CONTINGENT income withholding.

10. As to division of property: As to real property

As to personal property

11. As to division of debts:

12. As to change of name:

13. Other:

We certify that the above statements are our agreement.
PLAINTIFF (Print name) DEFENDANT (Print name) PLAINTIFF'S SIGNATURE DEFENDANT'S SIGNATURE DATE SIGNED DATE SIGNED

JD-FM-172 (Back) Rev. 2-07

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