Dissolution Of Marriage Report
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1DISSOLUTION OF MARRIAGE
STATE OF CONNECTICUT
REPORT
Instructions
SUPERIOR COURT
JD-FM-181 Rev. 11-09
1. To be completed by the Attorney for the Plaintiff or, if a
P.B. § 25-58
Self-Represented Person, by the Plaintiff.
2. Clerk to complete section 2.
PART 1
(To be completed by the Attorney for the Plaintiff or if a Self-Represented Person, by the Plaintiff)
Plaintiff
Name (First, middle, last)
Usual Residence (Number and street)
City or Town
State
Zip code
Birthplace (State or Foreign Country)
Attorney For Plaintiff (If Applicable) (Name)
Attorney's Address (If Applicable) (Number street, city, state, zip code)
Defendant
Name (First, middle, last)
Usual Residence (Number and street)
City or town
State
Zip code
Birthplace (State or Foreign Country)
Marital History
Place of This Marriage (City)
State
Zip code
Date of civil union that merged into marriage
Date of Marriage (Month, Day, Year)
Approximate Date Couple Separated (Month, Year)
by subsequent ceremony or by
operation of law (Month, Day, Year)
Number of Children Born Alive of This Marriage
Number of Children Still Living
Number of Children Under 18
Number of Children Under 23
Years of Age
Years of Age
CSSD Family Services Evaluation
CSSD Family Services Mediation
Conflict Resolution Conference
Issue Focused Evaluation
Yes
No
Yes
No
Yes
No
Yes
No
Public Assistance Recipient — Cash Recipient
Public Assistance Recipient — HUSKY
Attorney For minor Child(ren)
Guardian Ad Litem For Minor Child(ren)
Recipient (Medical)
Yes
No
Yes
No
Yes
No
Yes
No
Information For Statistical Purposes Only:
(To be completed by the Attorney for the Plaintiff or, if a Self-Represented Person, by the Plaintiff)
If Previously Married,
Education - Specify Highest Grade Completed
Number of This
How Many Ended By
Marriage (First,
Divorce or
Elementary
High School
College
Second, etc. specify)
Death
Annulment
(0,1,2,3, thru 8)
(1,2,3, or 4)
(1,2,3, 4 or 5+)
For Plaintiff
For Plaintiff
For Plaintiff
Plaintiff
Plaintiff
Plaintiff
For Defendant
For Defendant
For Defendant
Defendant
Defendant
Defendant
PART 2
(To be completed by the Clerk of Superior Court)
Decree
Date of Decree (Month, Day, Year)
Type of Decree
Date Writ Returnable (Month, Year)
Divorce
Annulment
Docket Number
Legal Grounds for Dissolution (Specify)
FA
Case Contested
Custody of Minor Children To
Yes
No
Plaintiff
Defendant
Joint
Not Applicable
Decree Granted To
Title of Official
Signed (Clerk or Assistant Clerk)
Plaintiff
Defendant
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