Fillable Superior Court Form printable pdf download

PARENTING EDUCATION

FOR COURT USE ONLY

STATE OF CONNECTICUT

PROGRAM - ORDER,

SUPERIOR COURT

ORDPEP (Order for participation)

CERTIFICATE AND RESULTS

FNOPEPF (Finding of inability to pay)

JD-FM-149 Rev. 11-12

CERTPEP (Certification of results)

C.G.S. §§ 46b-1, 46b-56, 46b-69b, 46b-231(m)(12)

Court Location

Instructions — Press Hard, you are making 4 copies.

To person taking part in the program:

To Clerk:

1. Provide name of case and docket number if available in designated boxes.

1. If program participation is ordered by the court or family support

magistrate, enter court location above and docket number and

2. Complete Section 2 if you are attending the Program to comply with the

complete section 1.

Automatic Orders or to comply with an order of the court or family support

2. Keep gold copy and give original and remaining copies to participant.

magistrate.

3. If you believe you are unable to pay or indigent, complete and submit form

To Service Provider:

JD-FM-75, Application for Waiver of Fees/Appointment of Counsel Family

1. Complete Section 3 and return original and green copy to the

appropriate Family Division Office.

before attending the program.

2. Give/send pink copy to participant.

4. YOU MUST bring this form and any approved Fee Waiver form to the

3. Keep yellow copy for your records.

service provider.

5. Select a service provider from a list available at the clerk's office and

To Family Services:

contact that provider to arrange attendance and to tell it the name of any

1. Upon receipt of Completion Certificate from service provider, complete

person that you do not want to be with in the same program.

section 4 and forward original to the superior court listed.

6. Give the original and ALL copies of the form to the service provider.

2. Keep green copy for your records.

Name of case (Plaintiff vs. Defendant)

Docket number

Section 1 - Court Order/Family Support Magistrate Order

(To be completed by Clerk)

Name of participant (Person taking part in the program)

(Select One)

Court Order

Family Support Magistrate Order

The participant named above has been ordered to take

All parties being present before the Family Support Magistrate

part in a parenting education program established

Division, it is ordered that the participant named above take part in a

under Section 46b-69b of the Connecticut General

parenting education program established under Section 46b-69b of

Statutes. The court finds that this individual:

the Connecticut General Statutes. It is found that participation is

necessary and that this individual:

(Select One)

Is Able to pay directly to the service provider the

Is Indigent or Unable to pay to take part in a parenting

appropriate fee for participating in a parenting

education program and all costs for participation in a program shall

education program.

be covered by the service provider under the provisions of Section

46b-69b of the Connecticut General Statutes.

By the Court/Family Support Magistrate Division (Print or type name of Judge/FSM)

Date Ordered

Signed (Judge, FSM, Assistant Clerk)

Section 2 - Participant Information

(To be completed by Participant - print or type)

Name and address of participant (Number, street, town and zip code)

"X" if applicable

I request not to be assigned to the same group as:

(Name of person)

"X" this box if you are attending the parenting education program to comply with the Automatic Orders (Section 25-5 of the Connect-

icut Practice Book).

Section 3 - Completion Certificate

(To be completed by Service Provider)

Name of Service Provider

Date(s) of Participation

Location at Which Program Was Provided

To: The Court Support Services Division, Family Services Unit of the Superior Court

The participant named above was scheduled to participate in our Parenting Education Program. It is certified that the participant:

satisfactorily completed the program.

did not satisfactorily complete the program for the following reason(s):

lack of attendance

other (specify):

Signed (Authorized Person)

Print or Type Name of Person Signing at Left

Date Signed

Section 4 - Participation Results

(To be completed by Family Services)

To: The Superior Court

The Court Support Services Division, Family Services Unit of the Superior Court certifies the results of participation as indicated above.

Superior Court Form

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