CUSTODY/VISITATION AGREEMENT JD-FM-183 Rev. 4/2000 C.G.S. § 46b-66 STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov INSTRUCTIONS: Complete form. Make copies for yourselves and give the original to the court clerk. JUDICIAL DISTRICT OF APPLICANT'S NAME (Last, first, middle initial) AT (Town ) DOCKET NO. RESPONDENT'S NAME (Last, first, middle initial) The parties agree that: 1. The custody of the child(ren) shall be as follows: Legal Custody: Primary Residence: 2. As to visitation with the child(ren): Who will pick up/drop off for visits: Holiday and school vacation visits: The amounts/percentages indicated below for child support, health insurance and unreimbursed medical costs, and child care costs must agree with the Child Support and Arrearage Guidelines (available at Clerk's Office) unless you meet one of the deviation criteria listed in the Guidelines. 3. As to current and/or past due child support: Agrees with the Child Support and Arrearage Guidelines Does not agree (give reason for deviation) Do not know (Continued on back/page 2) American LegalNet, Inc. www.FormsWorkflow.com 4. As to health insurance and unreimbursed medical costs: Agrees with the Child Support and Arrearage Guidelines Does not agree (give reason for deviation) Do not know 5. As to child care costs: Agrees with the Child Support and Arrearage Guidelines Does not agree (give reason for deviation) Do not know 6. Other We certify that the above statements are our agreement. APPLICANT (Print name) RESPONDENT (Print name) APPLICANT'S SIGNATURE RESPONDENT'S SIGNATURE DATE SIGNED DATE SIGNED JD-FM-183 (Back/Page 2) Rev. 4/2000 American LegalNet, Inc. www.FormsWorkflow.com