CUSTODY/VISITATION JUDGMENT JD-FM-184 Rev. 3-14 P.B. §§ 6-2 through 6-5, 17-4, 17-9, 17-43, 25-38 STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov ADA NOTICE COURT USE ONLY J FILE The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA. Docket number Instructions: Type or print with black ink and file with Court Clerk within 60 days of the judgment. Judicial District of At (Town) Name of Judge Date of Judgment Applicant's name (Last, first, middle initial) Respondent's name (Last, first, middle initial) Applicant's address Respondent's address Check here if additional parties are listed on the reverse (page 2). 1. An application asking for custody or visitation and other relief was filed in this court on (date): 2. Status of case (check one): Respondent filed an Appearance Respondent failed to file an Appearance (defaulted) and the Court finds that: (a) the Application was properly served on the Respondent, and (b) the Respondent is not now nor within the past thirty days has been, in the military service. 3. The Court in this case heard the evidence and finds the following (check all that apply): The applicant is the (State relationship) and the respondent is the (State relationship) of the following minor child(ren) with the following birth dates: Name of Child (First, middle, last) Date of birth (Month, day, year) The applicant and the respondent are living separate and apart. This Court has jurisdiction to make custody and visitation orders. The written agreement between the parties is fair and equitable under all the circumstances.. Based on these facts, the Court orders: The agreement between the parties is attached and its terms are incorporated by reference. Sole custody to: Joint legal custody to: Primary residence with: Visitation as follows: and (Continued on back/page 2) American LegalNet, Inc. www.FormsWorkFlow.com Docket number Child support as follows: Payable through the State of Connecticut Immediate income withholding. (See Notice to Nonappearing Obligor of Income Withholding Order, JD-FM-70, if Respondent has not filed an appearance.) Contingent income withholding Medical insurance coverage and unreimbursed medical costs as follows: Child care costs as follows: Regarding educational support orders, pursuant to Connecticut General Statute § 46b-56c: The Court finds that the parties have made a knowing and intelligent waiver of their right to request an educational support order; or The Court reserves jurisdiction to determine educational support orders; or The Court enters an educational support order (Attach additional sheets if necessary). Other: By the Court (Full name of Judge) Signed (Judge/Assistant Clerk) Print name of person signing at left Date of judgment ,J. Attorney Certification: (Completed by attorneys only if both the applicant and respondent were represented by attorneys) I hereby certify that the foregoing judgment file conforms to the judgment entered by the court. Applicant's attorney Print name Date signed Respondent's attorney Print name Date signed Continuation of Parties - Additional Applicants Name (Last, first, middle initial) Address Continuation of Parties - Additional Respondents Name (Last, first, middle initial) Address JD-FM-184 (Back/page 2) Rev. 3-14 (Page 2 of 2) American LegalNet, Inc. www.FormsWorkFlow.com