Free DISSOLUTION OF CIVIL UNION REPORT - Connecticut

DISSOLUTION OF CIVIL UNION REPORT
JD-FM-181A 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 Plaintiff (First, middle, last) Plaintiff's Birth Name if Different Than Stated (Last name only) City or Town State Birthplace (State or Foreign Country) Defendant's Birth Name if Different Than Stated (Last name only) City or Town State County Birthplace (State or Foreign Country) State Approximate Date Couple Separated (Month, Year) Number of Children Still Living Number of Children Under 18 Years of Age

Plaintiff Defendant Civil Union History

Usual Residence (Number and street) County Name of Defendant (First, middle, last) Usual Residence (Number and street) County Place of This Civil Union (City) Date of Civil Union (Mo., Day, Year) Number of Children of This Civil Union CSSD Family Services Evaluation

CSSD Family Services Mediation

Yes
Public Assistance Recipient

No No

Yes
Amount of Assistance Monthly

No

Yes
Attorney for Minor Child(ren)

Guardian Ad Litem 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 Prior Marriages and Civil Unions (First, Second, etc. specify) For Plaintiff For Defendant If Previously Married or Party to a Civil Union How Many ended By Dissolution or Death Annulment For Plaintiff For Plaintiff For Defendant For Defendant Education - Specify Highest Grade Completed Elementary (0,1,2,3, thru 8) Plaintiff Defendant High School (1,2,3, or 4) Plaintiff Defendant College (1,2,3, 4 or 5+) Plaintiff Defendant

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

Dissolution Decree

Annulment
Docket Number

FA Yes
Decree Granted To

No Defendant

Plaintiff
Title of Official

Defendant

Joint

Not Applicable

Signed (Clerk or Assistant Clerk)

Plaintiff

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