Free PARENTING EDUCATION PROGRAM - ORDER, CERTIFICATE AND RESULTS - Connecticut


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PARENTING EDUCATION PROGRAM - ORDER, CERTIFICATE AND RESULTS
JD-FM-149 Rev. 11-08 C.G.S. §§ 46b-1, 46b-56, 46b-69b, 46b-231(m)(12)

STATE OF CONNECTICUT

FOR COURT USE ONLY

SUPERIOR COURT
www.jud.ct.gov

ORDPEP (Order for participation) FNOPEPF (Finding of inability to pay) CERTPEP (Certification of results)
Court Location

Instructions -- Press Hard, you are making 4 copies.
To Participant: 1. Provide name of case and docket number if available in designated boxes. 2. Complete Section II if you are attending the Program to comply with the Automatic Orders or to comply with an order of the court or family support magistrate. 3. If you believe you are unable to pay or indigent, complete and submit form JD-FM-75, Application for Waiver of Fees/Appointment of Counsel before attending the program. 4. YOU MUST bring this form and any approved Fee Waiver form to the service provider. 5. Select a service provider from a list available at the clerk's office and contact that provider to arrange attendance and to tell it the name of any person that you do not want to be with in the same program. 6. Give the original and ALL copies of the form to the service provider.
Name of Case (Plaintiff vs. Defendant)

To Clerk: 1. If program participation is ordered by the court or family support magistrate, enter court location above and docket number and complete section I. 2. Keep gold copy and give original and remaining copies to participant. To Service Provider: 1. Complete Section III and return original and green copy to the appropriate Family Division Office. 2. Give/send pink copy to participant. 3. Keep yellow copy for your records. To Family Services: 1. Upon receipt of Completion Certificate from service provider, complete section IV and forward original to the superior court listed. 2. Keep green copy for your records.
Docket Number

Section I - Court Order/Family Support Magistrate Order (To be completed by Clerk)
Name of Participant

(Select One) Court Order The participant named above has been ordered to participate in a parenting education program established under C.G.S. § 46b-69b. The court finds that this individual: (Select One) Is Able to pay directly to the service provider the appropriate fee for participating in a parenting education program.

OR

Family Support Magistrate Order All parties being present before the Family Support Magistrate Division, it is ordered that the above-named participant participate in a parenting education program established pursuant to C.G.S. § 46b-69b. It is found that such participation is necessary and that this individual: Is Indigent or Unable to pay to participate in a parenting education program and all costs for participation in such a program shall be covered by the service provider pursuant to the provisions of C.G.S. § 46b-69b.
Signed (Judge, FSM, Assistant Clerk) Date Ordered

OR

By the Court/Family Support Magistrate Division (Print or type name of Judge/FSM)

Section II - Participant Information (To be completed by Participant - print or type)
Name and Address of Participant (Number, street, town and zip code) "X" if applicable

I request not to be assigned to the same group as: (Name of person) "X" this box if you are attending the parenting education program to comply with the Automatic Orders (Practice Book § 25-5).

Section III - Completion Certificate (To be completed by Service Provider)
Name of Service Provider Date(s) of Participation Location at Which Program Was Provided

To: The Court Support Services Division, Family Services Unit of the Superior Court The participant named above was scheduled to participate in our Parenting Education Program. It is certified that the participant: satisfactorily completed the program. other (specify):
Signed (Authorized Person) Print or Type Name of Person Signing at Left Date Signed

did not satisfactorily complete the program for the following reason(s):

lack of attendance

Section IV - Participation Results (To be completed by Family Services)
To: The Superior Court The Court Support Services Division, Family Services Unit of the Superior Court certifies the results of participation as indicated above.
Signed (Authorized Family Division Person) Print or Type Name of Person Signing at Left Date Signed

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