Free DISSOLUTION OF MARRIAGE -- REPORT - Connecticut

DISSOLUTION OF MARRIAGE REPORT
JD-FM-181 Rev. 4-08 P.B. § 25-58

Instructions 1. To be completed by the Attorney for the Plaintiff or, if a Self-Represented Person, by the Plaintiff. 2. Clerk to complete section 2.

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

PART 1 (To be completed by the Attorney for the Plaintiff or if a Self-Represented Person, by the Plaintiff)
Name of Husband (First, middle, last)

Husband

Usual Residence (Number and street) County Name of Wife (First, middle, last) State

City or Town Birthplace (State or Foreign Country)

Wife

Usual Residence (Number and street) County Place of This Marriage (City) Date of Marriage (Mo., Day, Year) Number of Children Born Alive of This Marriage Plaintiff State County

City or town Birthplace (State or Foreign Country) State Approximate Date Couple Separated (Month, Year) Number of Children Still Living CSSD Family Services Evaluation Number of Children Under 18 Years of Age CSSD Family Services Mediation

Marital History

Husband
Public Assistance Recipient

Wife No

Yes

No

Yes
Amount of Assistance Monthly Guardian Ad Litem For Minor Child(ren)

No

Yes
Attorney For minor Child(ren)

Yes

No

Yes

No

Attorney For Plaintiff (If Applicable) (Name)

Attorney's Address (If Applicable) (No., street, city, state, zip code)

Information For Statistical Purposes Only: (To be completed by the Attorney for the Plaintiff or, if a Self-Represented Person, by the Plaintiff)
Number of This Marriage (First, Second, etc. specify) For Husband For Wife If Previously Married, How Many Ended By Divorce or Death Annulment For Husband For Husband For Wife For Wife Education - Specify Highest Grade Completed Elementary (0,1,2,3, thru 8) Husband Wife High School (1,2,3, or 4) Husband Wife College (1,2,3, 4 or 5+) Husband Wife

PART 2 (To be completed by the Clerk of Superior Court)
Date of Decree (Mo., Day, Year) County of Decree Case Contested Type of Decree Date Writ Returnable (Month, Year)

Absolute Divorce Decree
Docket Number

Annulment
Legal Grounds for Dissolution (Specify)

FA
Custody of Minor Children To

Yes
Decree Granted To

No Wife

Husband
Title of Official

Wife

Joint

Not Applicable

Signed(Clerk or Assistant Clerk)

Husband

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