DISSOLUTION OF MARRIAGE REPORT JD-FM-181 Rev. 4-08 P.B. § 25-58 STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov Instructions 1. To be completed by the Attorney for the Plaintiff or, if a Self-Represented Person, by the Plaintiff. 2. Clerk to complete section 2. PART 1 (To be completed by the Attorney for the Plaintiff or if a Self-Represented Person, by the Plaintiff) Husband Name of Husband (First, middle, last) Usual Residence (Number and street) City or Town State County Birthplace (State or Foreign Country) Wife Name of Wife (First, middle, last) Usual Residence (Number and street) City or town State County Birthplace (State or Foreign Country) Place of This Marriage (City) County State Marital History Date of Marriage (Mo., Day, Year) Approximate Date Couple Separated (Month, Year) Number of Children Still Living Number of Children Born Alive of This Marriage Plaintiff Number of Children Under 18 Years of Age CSSD Family Services Evaluation Wife Husband Yes CSSD Family Services Mediation No Yes Public Assistance Recipient No Amount of Assistance Monthly No Yes Attorney For minor Child(ren) Guardian Ad Litem For Minor Child(ren) Yes No Yes Attorney For Plaintiff (If Applicable) (Name) No Attorney's Address (If Applicable) (No., street, city, state, zip code) Information For Statistical Purposes Only: (To be completed by the Attorney for the Plaintiff or, if a Self-Represented Person, by the Plaintiff) For Husband If Previously Married, How Many Ended By Divorce or Death Annulment For Husband For Husband Elementary (0,1,2,3, thru 8) Husband High School (1,2,3, or 4) Husband College (1,2,3, 4 or 5+) Husband For Wife For Wife Wife Wife Wife Number of This Marriage (First, Second, etc. specify) For Wife Education - Specify Highest Grade Completed PART 2 (To be completed by the Clerk of Superior Court) Date of Decree (Mo., Day, Year) Type of Decree Date Writ Returnable (Month, Year) Decree Absolute Divorce County of Decree Annulment Docket Number Legal Grounds for Dissolution (Specify) FA Case Contested Yes Custody of Minor Children To No Decree Granted To Husband Husband Title of Official Wife Joint Not Applicable Signed(Clerk or Assistant Clerk) Wife American LegalNet, Inc. www.FormsWorkflow.com