Free CERTIFICATION OF NOTICE IN FAMILY CASES (PUBLIC ASSISTANCE) - Connecticut

CERTIFICATION OF NOTICE IN FAMILY CASES (PUBLIC ASSISTANCE)
JD-FM-175 Rev. 5-06 P.B. §§ 10-12 through 10-17, 5-2 C.G.S. § 46b-55

STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov
INSTRUCTIONS

COURT USE ONLY

CERTPA

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.
AT (Town) RETURN DATE (Mo., day, year) (if applicable) DOCKET NO. (If known)

JUDICIAL DISTRICT OF NAME OF CASE

(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 And State Marshal's return was mailed/delivered on (month, day, year) to:

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:

(No , street, town) SIGNATURE ADDRESS (No , street, town, state, zip code) PRINT NAME TELEPHONE NO. (Area code first)

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