DISSOLUTION AGREEMENT
Court Use Only
JD-FM-172 Rev. 7-10
STATE OF CONNECTICUT
AGREMNT
C.G.S. §§ 46b-51, 46b-38oo
SUPERIOR COURT
*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 /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):
(Continued on back/next page)
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