Fill and Sign the Dissolution of Civil Union Complaint Connecticut Form

DissolutionAnnulment Type of Decree Defendant Plaintiff Decree Granted To Not Applicable Joint Defendant Plaintiff Custody of Minor Children To No Yes Case Contested Public Assistance Recipient CSSD Family Services Evaluation CSSD Family Services Mediation Yes No Attorney for Minor Child(ren) Guardian Ad Litem for Minor Child(ren) DISSOLUTION OF CIVIL UNION REPORT STATE OF CONNECTICUT SUPERIOR COURT JD-FM-181A Rev. 4-08 P.B. § 25-58 Name of Plaintiff (First, middle, last) 1. To be completed by the Attorney for the Plaintiff or, if a Self-Represented Person, by the Plaintiff. 2. Clerk to complete section 2. Plaintiff Amount of Assistance Monthly Signed (Clerk or Assistant Clerk) PART 1 (To be completed by the Attorney for the Plaintiff or, if a Self-Represented Person, by the Plaintiff) Instructions Usual Residence (Number and street) City or Town County State Birthplace (State or Foreign Country) Defendant Name of Defendant (First, middle, last) Usual Residence (Number and street) City or Town County State Birthplace (State or Foreign Country) Defendant's Birth Name if Different Than Stated (Last name only) Civil Union History Place of This Civil Union (City) County State Approximate Date Couple Separated (Month, Year) Date of Civil Union (Mo., Day, Year) Number of Children of This Civil Union Number of Children Still Living Number of Children Under 18 Years of Age Yes No YesNo Attorney For Plaintiff (If Applicable) (Name) Attorney's Address (If Applicable) (No., street, city, state, zip code) INFORMATION FOR STATISTICAL PURPOSES ONLY: (To be completed by the Attorney for the Plaintiff or, if a Self-Represented Person, by the Plaintiff) Date of Decree (Mo., Day, Year) Date Writ Returnable (Month, Year) County of Decree Number of Prior Marriages and Civil Unions (First, Second, etc. specify) For Defendant If Previously Married or Party to a Civil Union How Many ended By Death Dissolution orAnnulment For Plaintiff For Plaintiff For Defendant For Plaintiff For Defendant Education - Specify Highest Grade Completed Elementary (0,1,2,3, thru 8) High School (1,2,3, or 4) College (1,2,3, 4 or 5+) Plaintiff Defendant Plaintiff Defendant Plaintiff Defendant PART 2 (To be completed by the Clerk of Superior Court) Decree Title of Official Docket Number FA www jud.ct.gov Yes No YesNo Plaintiff's Birth Name if Different Than Stated (Last name only)