Form Jd-Fm-183 - Custody/visitation Agreement - State Of Connecticut Superior Court Page 2
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2The amounts/percentages indicated below for Child Support, Health Care Insurance Coverage, Unreimbursed Health Care
Costs, and Child Care Costs must follow the Child Support and Arrearage Guidelines (the Guidelines), unless you meet one
of the deviation criteria in the Guidelines (reasons for an amount different than the Guidelines). The Guidelines are available at
any Judicial District Clerk's Office, the Court Service Centers, and on the Judicial Branch web site - .
5. As to current and/or past due child support:
This amount follows
This amount is different from the Guidelines (deviation)
the Guidelines
Give reasons for deviation from the Guidelines (See Guidelines for reason that applies)
6. As to health insurance and unreimbursed medical costs:
This amount follows
This amount is different from the Guidelines (deviation)
the Guidelines
Give reasons for deviation from the Guidelines (See Guidelines for reason that applies)
7. As to child care costs:
This amount follows
This amount is different from the Guidelines (deviation)
the Guidelines
Give reasons for deviation from the Guidelines (See Guidelines for reason that applies)
8. Other
We hereby certify that the above conforms with the agreement of the parties.
Signed (Plaintiff/Plaintiff's attorney)
Date
Signed (Defendant/Defendant's attorney)
Date
Signed (Guardian ad Litem/Attorney for the Minor Child)
Date
Approved and so ordered (Judge/Family Support Magistrate)
Date
JD-FM-183 (Back/Page 2) Rev. 7-17
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