Form JD-FM-172 "Dissolution Agreement" - Connecticut

What Is Form JD-FM-172?

This is a legal form that was released by the Connecticut Superior Court - a government authority operating within Connecticut. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on May 1, 2016;
  • The latest edition provided by the Connecticut Superior Court;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form JD-FM-172 by clicking the link below or browse more documents and templates provided by the Connecticut Superior Court.

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Download Form JD-FM-172 "Dissolution Agreement" - Connecticut

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STATE OF CONNECTICUT
Court Use Only
DISSOLUTION AGREEMENT
AGREMNT
SUPERIOR COURT
JD-FM-172
Rev. 5-16
www.jud.ct.gov
C.G.S. § 46b-51
*AGREMNT*
Instructions: The instructions for filling out this form are on form JD-FM-172A.
Judicial District of
At (Town)
Docket number
Plaintiff's name (Last, first middle initial)
Defendant's name (Last, first, middle initial)
The plaintiff and defendant agree that:
1. Our
marriage
civil union
has broken down irretrievably.
("X" one)
2. The custody of the child(ren) shall be as follows:
Joint legal custody to
and
Primary residence with:
A parenting responsibility plan in the best interest(s) of the minor child(ren)
shall be incorporated by reference or
as follows:
Sole custody to:
3. As to visitation with the child(ren):
Who will pick up/drop off for visits or parenting time transition:
Holiday and school vacation schedule:
The amounts/percentages indicated below for Child Support, Health Care Insurance Coverage and Unreimbursed
Health Care Costs, and Child Care Costs must follow the Child Support and Arrearage Guidelines (the Guidelines), which
are available at Clerk's Offices and on the Judicial Branch website at www.jud.ct.gov/publications, unless you ask for one of
the deviation criteria to apply (reasons for an amount different than the Guidelines).
4. As to current and/or past due Child Support:
This amount follows the Guidelines.
This amount is different from the Guidelines (deviation). Give reason for deviation from the Guidelines
(see Guidelines for reason that applies):
5. As to the child's or children's required Health Care Insurance Coverage and Unreimbursed Health Care Costs:
This amount follows the Guidelines.
This amount is different from the Guidelines (deviation). Give reason for deviation from the Guidelines
(see Guidelines for reason that applies):
6. As to Child Care Costs that qualify under the Guidelines:
This amount follows the Guidelines.
This amount is different from the Guidelines (deviation). Give reason for deviation from the Guidelines
(see Guidelines for reason that applies):
(Continued on back/next page)
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STATE OF CONNECTICUT
Court Use Only
DISSOLUTION AGREEMENT
AGREMNT
SUPERIOR COURT
JD-FM-172
Rev. 5-16
www.jud.ct.gov
C.G.S. § 46b-51
*AGREMNT*
Instructions: The instructions for filling out this form are on form JD-FM-172A.
Judicial District of
At (Town)
Docket number
Plaintiff's name (Last, first middle initial)
Defendant's name (Last, first, middle initial)
The plaintiff and defendant agree that:
1. Our
marriage
civil union
has broken down irretrievably.
("X" one)
2. The custody of the child(ren) shall be as follows:
Joint legal custody to
and
Primary residence with:
A parenting responsibility plan in the best interest(s) of the minor child(ren)
shall be incorporated by reference or
as follows:
Sole custody to:
3. As to visitation with the child(ren):
Who will pick up/drop off for visits or parenting time transition:
Holiday and school vacation schedule:
The amounts/percentages indicated below for Child Support, Health Care Insurance Coverage and Unreimbursed
Health Care Costs, and Child Care Costs must follow the Child Support and Arrearage Guidelines (the Guidelines), which
are available at Clerk's Offices and on the Judicial Branch website at www.jud.ct.gov/publications, unless you ask for one of
the deviation criteria to apply (reasons for an amount different than the Guidelines).
4. As to current and/or past due Child Support:
This amount follows the Guidelines.
This amount is different from the Guidelines (deviation). Give reason for deviation from the Guidelines
(see Guidelines for reason that applies):
5. As to the child's or children's required Health Care Insurance Coverage and Unreimbursed Health Care Costs:
This amount follows the Guidelines.
This amount is different from the Guidelines (deviation). Give reason for deviation from the Guidelines
(see Guidelines for reason that applies):
6. As to Child Care Costs that qualify under the Guidelines:
This amount follows the Guidelines.
This amount is different from the Guidelines (deviation). Give reason for deviation from the Guidelines
(see Guidelines for reason that applies):
(Continued on back/next page)
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7. As to post-majority educational support ("x" one):
Both of the parties have made a knowing and intelligent waiver of their right to request a post-majority educational
support order; or
The parties ask the Court to reserve jurisdiction to determine whether a post-majority educational support order
should issue and the terms of the order; or
The parties ask the Court to find that it is more likely than not that the parents would have provided post-majority
educational support, and for the Court to reserve jurisdiction to determine whether to enter an educational support
order and the terms of the order; or
The parties ask the Court to enter a post-majority education support as follows
(Attach additional sheets if necessary):
8. As to alimony:
9. As to income withholding, we understand that the support orders are by immediate income withholding unless for cause
or we both agree to it being contingent: We agree to a(n)
Immediate
Contingent
income withholding.
10. As to division of property:
As to real property
As to personal property
As to pensions and retirement accounts
11. As to division of debts:
12. As to the change of name:
Plaintiff's name is restored to the
birthname of
or
.
former name of
Defendant's name is restored to the
birthname of
or
.
former name of
13. Other:
We certify that the above statements are our agreement.
Plaintiff (Print name)
Date signed
Plaintiff's signature
Date signed
Defendant (Print name)
Defendant's signature
ADA NOTICE
The Judicial Branch of the State of Connecticut complies with the
Americans with Disabilities Act (ADA). If you need a reasonable
accommodation in accordance with the ADA, contact a court
clerk or an ADA contact person listed at www.jud.ct.gov/ADA.
JD-FM-172 (Back) Rev. 5-16
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