(Continued on page 2)The ("X" one)of the dissolution of civil union complaint or before the dissolution of civil union will become final.5. A dissolution of civil union is granted based on the3. "X" one:.DISSOLUTION OF CIVIL UNION JUDGMENT JD-FM-177A Rev. 10-18 C.G.S 247 46b-38tt; P.A. 18-14; P.B. 247247 6-2 through 6-5, 17-4, 17-9, 17-43, 25-38 1. A complaint asking for a dissolution of civil union and other relief was filed in this court with a return date of:Defendant filed an Appearance.INSTRUCTIONS: Type or print with black ink and file with Court Clerk within 60 days of the judgment.This civil union has broken down irretrievably and there is no possibility of getting back together.Other (must be reason(s) listed in Connecticut General Statutes section 46b-40(c)):6. "X" all that apply:No children were born to either the plaintiff or defendant after the date of this civil union.There are no children of this civil union. JFILE COURT USE ONLY2. Status of case ("X" one): Date of birth (Month, day, year) Name of child (First, middle, last)STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.govThe plaintiff,4. "X" one:at , and defendant,Defendant failed to file an appearance (defaulted) and the Court finds that: (a) the complaint was properly served on the defendant, and (b) the defendant is not now, nor within the past thirty days has been, in the military service.The following children were born after the date of this civil union to the ("X" all that apply) and are not the children of the other party to this civil union. Name of child (First, middle, last) Date of birth (Month, day, year)7.("X" if it applies) The Court finds that the agreement between the parties is fair and equitable.The following children have been born to theon, or after the date of this civil union and the other party to this civil union is the parent/adoptive parent.The ("X" one) then returned to Connecticut, planning to live here permanently.The civil union broke down after the ("X" one)entered a civil union on, Judicial District of At (Town) Docket number Name of Judge Date of judgment Plaintiff's name (Last, first, middle initial) Defendant's name (Last, first, middle initial) Plaintiff's address Defendant's address Return date (Name before civil union) (Name before civil union) (Month, day, year) (Town and state) plaintiff defendant has lived in Connecticut for at least twelve months before the filing plaintiff defendant lived in Connecticut at the time of the civil union, moved away, and plaintiff defendant moved to Connecticut. complaint cross complaint because ("X" one): plaintiff defendant plaintiff defendant or have been adopted before, *JFILE* The Court in this case heard the evidence and finds the following: The plaintiff has attested, under oath, that the necessary conditions required for the entry of a judgment without ahearing have been met. The Court has considered the evidence without a hearing and finds the following: American LegalNet, Inc. www.FormsWorkFlow.com (Page 2 of 2)JD-FM-177A Rev. 10-18 By the Court (Full name of Judge),J.Based on these facts, the Court enters a judgment of dissolution of civil union and declares each party to be single. The Court further orders:Sole custody toand Visitation as follows:Alimony payable to:Child support as follows:Payable through the State of Connecticut.Medical insurance coverage as follows:Immediate income withholding (See Notice to Nonappearing Obligor of Income Withholding Order, JD-FM-70, if defendant has not filed an appearance)Regarding educational support orders, pursuant to Connecticut General Statues 247 46b-56c:Other:to Signed (Judge/Assistant Clerk) Plaintiff's attorney Defendant's attorneyI certify that the foregoing judgment file conforms to the judgment entered by the court.Notice as directed by the judicial authority must be given to parties who have not filed an appearance, of any order for support or alimony. No such order shall be effective until the order of notice has been complied with or the nonappearing party has actually received notice of such order. (Practice Book section 25-29) The Court finds that the parties have made a knowing and intelligent waiver of their right to request a educational support order; or The Court enters an educational support order (Attach additional sheets if necessary).to terminate atAmount: $ Attorney Certification: (Completed by attorneys only if both the plaintiff and defendant were represented by attorneys)Primary residence with:Joint legal custody toContingent income withholdingThe agreement between the parties is attached and its terms are incorporated by reference. Name change fromThe Court reserves jurisdiction to determine educational support orders; or Docket number Print name of person signing at left Print name Print name Date signed Date signed Date of judgment American LegalNet, Inc. www.FormsWorkFlow.com