DISSOLUTION OF CIVIL UNION JUDGMENT
JD-FM-177A New 10-05 P.A. 05-10 P.B. §§ 6-2 through 6-5, 17-4, 17-9, 17-43, 25-38
STATE OF CONNECTICUT SUPERIOR COURT www jud.ct.gov
COURT USE ONLY
INSTRUCTIONS: Type or print with black ink and file with Court Clerk within 60 days of the judgment.
JUDICIAL DISTRICT OF NAME OF JUDGE PLAINTIFF'S NAME (Last, first, middle initial) PLAINTIFF'S ADDRESS AT (Town) DATE OF JUDGMENT DEFENDANT'S NAME (Last, first, middle initial) DEFENDANT'S ADDRESS DOCKET NO.
1. A complaint asking for a dissolution of civil union and other relief was filed in this court with a return date of: 2. Status of case (check one):
Defendant filed an Appearance. Defendant failed to file an appearance (defaulted) and the Court finds that: (a) the complaint was properly served on the defendant, and (b) the defendant is not now, nor within the past thirty days has been, in the military service. 3. The Court in this case heard the evidence and finds the following: The plaintiff,
(Name before civil union)
, and defendant,
(Name before civil union)
entered a civil union on
(Month, day, year)
(Town and state)
4. Check one: The ("X" one) plaintiff defendant has lived in Connecticut for at least twelve months before the filing of the dissolution of civil union complaint or before the dissolution of civil union will become final. The ("X" one) plaintiff defendant lived in Connecticut at the time of the civil union, moved away, and then returned to Connecticut, planning to live here permanently. plaintiff defendant The civil union broke down after the ("X" one) moved to Connecticut. 5. A dissolution of civil union is granted based on the complaint cross complaint because (check one):
This civil union has broken down irretrievably and there is no possibility of getting back together. Other (must be reason(s) listed in Connecticut General Statutes § 46b-40(c)):
6. Check all that apply: No children were born to either the plaintiff or defendant after the date of this civil union. There are no minor children of this civil union. The following children have been born to the plaintiff defendant or have been adopted before, on, or after the date of this civil union and the other party to this civil union is the parent/adoptive parent.
NAME OF CHILD (First, middle, last) DATE OF BIRTH (Month, day, year)
(Continued on reverse/page 2)
6. (Continued) The following children were born after the date of this civil union to the ("X" all that apply) and are not the children of the other party to this civil union.
NAME OF CHILD (First, middle, last)
DATE OF BIRTH (Month, day, year)
(Check if it applies) The Court finds that the agreement between the parties is fair and equitable.
Based on these facts, the Court enters a judgment of dissolution of civil union and declares each party single. The Court further orders: The agreement between the parties is attached and its terms are incorporated by reference. Sole custody to Joint legal custody to Primary residence with: Visitation as follows:
Alimony payable to: Amount: $ to terminate at
Child support as follows: Payable through the State of Connecticut. Medical insurance coverage as follows: Immediate income withholding (See Notice to Nonappearing Obligor of Income Withholding Order, JD-FM-70, if defendant has not filed an appearance) Contingent income withholding Regarding educational support orders, pursuant to Connecticut General Statutes § 46b-56c: The Court finds that the parties have made a knowing and intelligent waiver of their right to request an educational support order; or The Court reserves jurisdiction to determine educational support orders; or The Court enters an educational support order (Attach additional sheets if necessary). Name change from Other: Notice as directed by the judicial authority must be given to parties who have not filed an appearance, of any order for support or alimony. No such order shall be effective until the order of notice has been complied with or the nonappearing party has actually received notice of such order. (P.B. § 25-29)
BY THE COURT (Full name of Judge) SIGNED (Judge/Assistant Clerk) PRINT NAME OF PERSON SIGNING AT LEFT DATE OF JUDGMENT
Attorney Certification: (Completed by attorneys only if both the plaintiff and defendant were represented by attorneys)
I certify that the foregoing judgment file conforms to the judgment entered by the Court.
PLAINTIFF'S ATTORNEY DEFENDANT'S ATTORNEY PRINT NAME PRINT NAME DATE SIGNED DATE SIGNED
JD-FM-177A (Back) New 10-05
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