APPEAL FROM FAMILY SUPPORT MAGISTRATE JD-FM-111 Rev. 3-17 C.G.S. � 46b-231(n), P.B. �� 25a-5, 25a-29 STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov ADA NOTICE 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. COURT USE ONLY APFFSM *APFFSM* Instructions To Person Appealing The Decision (Appellant) 1. Type or print this form neatly and sign the certification section below. 2. Give the reasons for the appeal on this form and, if necessary, on a separate piece of paper with the title of Petition and attach that petition to this form. 3. Mail or deliver a copy of this form and all sheets that are attached, if any, to each party in the case, and mail one copy, by certified mail, to the following address: OFFICE OF ATTORNEY GENERAL, CHILD SUPPORT DEPARTMENT, 55 ELM ST., HARTFORD, CT 06106 4. Give this form, and all sheets that are attached, if any, to the clerk of the court for the Judicial District where the magistrate's decision was made WITHIN 14 DAYS OF: a. the date the final decision of the magistrate was given to the clerk, or b. if a rehearing was asked for, and a decision was made on that request, the date the notice of the decision on the request was given to the clerk, whichever is later. Name of case Name and address of Court Date magistrate's decision was filed with (given to) the Court Instructions To Clerk 1. Provide a copy of the filed appeal form and all sheets that are attached, if any, to the Family Support Magistrate whose decision is being appealed. 2. Provide a copy of the Superior Court Judge's verbal or written decision on the appeal to the Family Support Magistrate. 3. Code this appeal into the court file using the docket legend on this form. If this is an appeal from a Uniform Interstate Child Support Act (UIFSA) matter and there is no existing court file, create one using the F87 case type. Docket number Name of magistrate who made decision Date decision on request for rehearing was filed with the Court (If a request was filed) Attorney for respondent (Include Juris number) or name of selfrepresented party Attorneys or self-represented (pro se) party or parties at magistrate hearing Transcript u Attorney for plaintiff (Include Juris number) or name of self-represented party Has been ordered Additional evidence requested Not necessary No Explain why a transcript is not necessary (if applicable): Yes - If yes, attach statement pursuant to section 46b-231(n)(5) of the Connecticut General Statutes Notice When a Family Support Magistrate decision is appealed, the support order remains in effect until the appeal is decided. When the appeal is decided, the decision may change the original support order or the original support order may remain in effect without any changes. Any order made by the court as a result of this appeal may be made effective beginning on the date the original order was made. Petition The reasons for this appeal are:* *If necessary, attach additional sheet(s). Signed (Attorney or self-represented party) Telephone number Mailing address Juris number of attorney Appeal by: Name of person signing above (type or print) Certification I certify that a copy of this document and all attachments to it, if any, were mailed or delivered electronically or non-electronically to all attorneys and self-represented parties of record on and that written consent for electronic delivery was received from all attorneys and self-represented parties receiving electronic delivery. Name and address of each party and attorney that copy was mailed or delivered to* *If necessary, attach additional sheet or sheets with name and address which the copy was mailed or delivered to. Signed (Attorney or self-represented party) u Print or type name and mailing address of person signing Court Use Only File date I further certify that a copy was mailed, by certified mail, to the Office of the Attorney General, Child Support Department, 55 Elm Street, Hartford, CT 06106. American LegalNet, Inc. www.FormsWorkFlow.com