Free JD-FM-184 - Connecticut

CUSTODY/VISITATION JUDGMENT
JD-FM-184 Rev. 8-06 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

J FILE

INSTRUCTIONS: Type or print with black ink and file with Court Clerk within 60 days of the judgment.
JUDICIAL DISTRICT OF NAME OF JUDGE APPLICANT'S NAME (Last, first, middle initial) APPLICANT'S ADDRESS AT (Town) DATE OF JUDGMENT RESPONDENT'S NAME (Last, first, middle initial) RESPONDENT'S ADDRESS DOCKET NO.

Check here if additional parties are listed on the reverse (page 2). 1. An application asking for custody or visitation and other relief was filed in this court on (date): 2. Status of case (check one): Respondent filed an Appearance Respondent failed to file an Appearance (defaulted) and the Court finds that: (a) the Application was properly served on the Respondent, and (b) the Respondent 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 (check all that apply): The applicant is the
(State relationship)

and the respondent is the
(State relationship)

of the following minor child(ren) with the following birth dates:
NAME OF CHILD (First, middle, last) DATE OF BIRTH (Month, day, year)

The applicant and the respondent are living separate and apart. This Court has jurisdiction to make custody and visitation orders. The written agreement between the parties is fair and equitable under all the circumstances.. Based on these facts, the Court 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: and

(Continued on back/page 2)

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DOCKET NO.

Child support as follows: Payable through the State of Connecticut Immediate income withholding. (See Notice to Nonappearing Obligor of Income Withholding Order, JD-FM-70, if
Respondent has not filed an appearance.)

Contingent income withholding Medical insurance coverage and unreimbursed medical costs as follows:

Child care costs as follows:

Regarding educational support orders, pursuant to Connecticut General Statute § 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). Other:

BY THE COURT (Full name of Judge)

SIGNED (Judge/Assistant Clerk)

PRINT NAME OF PERSON SIGNING AT LEFT

DATE OF JUDGMENT

,J.
Attorney Certification:
(Completed by attorneys only if both the applicant and respondent were represented by attorneys)

I hereby certify that the foregoing judgment file conforms to the judgment entered by the court.
APPLICANT'S ATTORNEY RESPONDENT'S ATTORNEY PRINT NAME PRINT NAME DATE SIGNED DATE SIGNED

CONTINUATION OF PARTIES - ADDITIONAL APPLICANTS
NAME (Last, first, middle initial) ADDRESS

CONTINUATION OF PARTIES - ADDITIONAL RESPONDENTS
NAME (Last, first, middle initial) ADDRESS

JD-FM-184 (Back/page 2) Rev. 8-06

(Page 2 of 2)

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