CERTIFICATION OF NOTICE IN FAMILY CASES (PUBLIC ASSISTANCE) JD-FM-175 Rev. 10-15 P.B. §§ 10-12 through 10-17, 25-2 C.G.S. § 46b-55 ; P.A. 15-7 STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov COURT USE ONLY CERTPA *CERTPA* Instructions If you, your spouse, or your children have ever received public assistance (state aid, city aid, or welfare) follow the instructions below (you do not have to fill out this form if your case is only about visitation): 1. Mail or deliver a copy of the Summons and Complaint, Custody Application, or Joint Petition, Notice of Automatic Court Orders, Order to Attend Hearing (if applicable), Agreement (if applicable), and a copy of the State Marshal's return (proof that the court papers were delivered/served, if applicable) to the Attorney General if the aid was provided by the State of Connecticut or to the Town Clerk's office if the aid was provided by a city or town. 2. Fill out this form. 3. Keep a copy for your records. 4. File this Certification form with the court clerk when you file your Summons and Complaint, Custody Application or Joint Petition. Judicial District of Name of case At (Town) Return date (Month, day, year) (if applicable) Docket number (If known) (Check all that apply) This is to certify that a true copy of the: Joint Petition (only for nonadversarial divorce) Summons Complaint Custody Application (only if seeking child support) Notice of Automatic Court Orders Order to Attend Hearing (for custody actions seeking support) Affidavit Concerning Children (for proceedings seeking custody) Financial Affidavit Agreement (if applicable) State Marshal's return (if applicable) was mailed or delivered on (month, day, year) The Office of the Attorney General 55 Elm Street Hartford, CT 06106 If any party or any child received public assistance from any town or city in the State of Connecticut: The City Clerk for the town providing public assistance: to: (check all that apply) If any party or any child received public assistance from the State of Connecticut: (Number, street, town) Signature Address (Number, street, town, state, zip code) Print name Telephone number (Area code first) 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. American LegalNet, Inc. www.FormsWorkFlow.com