DISSOLUTION AGREEMENT JD-FM-172 Rev. 5-16 C.G.S. � 46b-51 STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov Court Use Only AGREMNT Instructions: The instructions for filling out this form are on form JD-FM-172A. Judicial District of Plaintiff's name (Last, first middle initial) At (Town) Defendant's name (Last, first, middle initial) Docket number *AGREMNT* The plaintiff and defendant agree that: 1. Our ("X" one) marriage civil union has broken down irretrievably. and 2. The custody of the child(ren) shall be as follows: Joint legal custody to Primary residence with: A parenting responsibility plan in the best interest(s) of the minor child(ren) shall be incorporated by reference or as follows: Sole custody to: 3. As to visitation with the child(ren): Who will pick up/drop off for visits or parenting time transition: Holiday and school vacation schedule: The amounts/percentages indicated below for Child Support, Health Care Insurance Coverage and Unreimbursed Health Care Costs, and Child Care Costs must follow the Child Support and Arrearage Guidelines (the Guidelines), which are available at Clerk's Offices and on the Judicial Branch website at www.jud.ct.gov/publications, unless you ask for one of the deviation criteria to apply (reasons for an amount different than the Guidelines). 4. As to current and/or past due Child Support: This amount follows the Guidelines. This amount is different from the Guidelines (deviation). Give reason for deviation from the Guidelines (see Guidelines for reason that applies): 5. As to the child's or children's required Health Care Insurance Coverage and Unreimbursed Health Care Costs: This amount follows the Guidelines. This amount is different from the Guidelines (deviation). Give reason for deviation from the Guidelines (see Guidelines for reason that applies): 6. As to Child Care Costs that qualify under the Guidelines: This amount follows the Guidelines. This amount is different from the Guidelines (deviation). Give reason for deviation from the Guidelines (see Guidelines for reason that applies): (Continued on back/next page) American LegalNet, Inc. www.FormsWorkFlow.com 7. As to post-majority educational support ("x" one): Both of the parties have made a knowing and intelligent waiver of their right to request a post-majority educational support order; or The parties ask the Court to reserve jurisdiction to determine whether a post-majority educational support order should issue and the terms of the order; or The parties ask the Court to find that it is more likely than not that the parents would have provided post-majority educational support, and for the Court to reserve jurisdiction to determine whether to enter an educational support order and the terms of the order; or The parties ask the Court to enter a post-majority education support as follows (Attach additional sheets if necessary): 8. As to alimony: 9. As to income withholding, we understand that the support orders are by immediate income withholding unless for cause or we both agree to it being contingent: We agree to a(n) Immediate Contingent income withholding. 10. As to division of property: As to real property As to personal property As to pensions and retirement accounts 11. As to division of debts: 12. As to the change of name: Plaintiff's name is restored to the or or 13. Other: former name of birthname of . former name of Defendant's name is restored to the birthname of . We certify that the above statements are our agreement. Plaintiff (Print name) Defendant (Print name) Plaintiff's signature Defendant's signature Date signed Date signed 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. JD-FM-172 (Back) Rev. 5-16 American LegalNet, Inc. www.FormsWorkFlow.com ADA NOTICE