MOTION FOR MODIFICATION JD-FM-174 Rev. 2-13 C.G.S. §§ 46b-84, 46b-86 P.B. §§ 25-26, 25-30, 25-57, 25a-18, 25a-30 STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov COURT USE ONLY MFMOD (Check one) *MFMOD* Docket Number Before judgment Judicial District of After judgment (If the court has ordered you to attach a request for leave with a motion for modification of a final custody or visitation order, you must complete and attach a Request for Leave form (JD-FM-202) to this motion.) At (Town) Plaintiff's Name (Last, first, middle initial) Plaintiff's Address (Number, street, city, state, zip code) Defendant's Name (Last, first, middle initial) Defendant's Address (Number, street, city, state, zip code) Type of Motion to Modify Child Support Alimony (Name) Custody Visitation Other (Specify): I, respectfully represent that: 1. This Court issued an order dated , the Plaintiff the Defendant a Support Enforcement Officer, directing (Name) , residing at , to: (Complete the boxes that apply to your motion) (Number, street, city, state, zip code) Pay current support in the amount of: Pay alimony in the amount of: $ $ every (per) every (per) Joint legal custody No Yes % or $ Sole custody $ every (per) as of (date) Primary residence of children with: Pay arrearages as follows: on the total arrearage owed of $ Have visitation or parenting time as follows: Have custody of the child/children: (Check one) Provide health insurance coverage Provide HUSKY/cash medical Pay % of unreimbursed medical expenses $ every (per) Contribute to child care Other (Specify): 2. You must explain briefly the facts that are the reasons why you are asking for this modification. (Check appropriate box or boxes. Attach additional sheet or sheets if necessary.) Since the date of the order, the circumstances concerning this case have changed substantially as follows: The order for current child support is substantially different from the current child support and arrearage guidelines presumptive child support order as follows: 3. The plaintiff defendant is a "deploying parent" of the armed forces. The facts about that deployment or mobilization are: Yes No 4.a. I am receiving state assistance or HUSKY health insurance, or I have received it in the past. Yes 4.b. Any child that this motion is about is receiving state assistance or HUSKY health insurance, or has received it in the past. If you answered "Yes" to either of these questions, you must send a copy of this motion to: The Office of the Attorney General, 55 Elm Street, Hartford, CT 06106. If you don't give the Attorney General's Office a copy, your motion may take longer to decide. No I ask the Court to modify the existing order or orders as follows: (Check all that apply) a. Child Support (You must file a sworn to Financial Affidavit (JD-FM-6) at least 5 days before the hearing. You must also file an Affidavit Concerning Children (JD-FM-164), a completed Worksheet for the Connecticut Child Support and Arrearage Guidelines (CCSG-1, JD FM 220), and an Advisement of Rights Re: Income Withholding (JD-FM-71) on your hearing date). Order current support Increase current support Decrease current support Find arrearage and order payment Provide HUSKY/cash medical Contribute to child care Order immediate income withholding Provide health insurance coverage Other b. Alimony (You must file a sworn to Financial Affidavit (JD-FM-6) at least 5 days before the hearing. You must also file an Advisement of Rights Re: Income Withholding (JD FM 71) on your hearing date). c. Custody (You must file a sworn to Financial Affidavit (JD-FM-6) at least 5 days before the hearing. You must also file an Affidavit Concerning Children (JD FM 164) and a completed Worksheet for the Connecticut Child Support and Arrearage Guidelines (CCSG-1, JD-FM-220) on your hearing date). Increase Decrease the amount of alimony to be paid. (Continued on back/page 2) Modify custody as follows: Superior Court Family Support Magistrate Division American LegalNet, Inc. www.FormsWorkFlow.com Check appropriate court: Plaintiff's Name (Last, first, middle initial) Defendant's Name (Last, first, middle initial) Docket Number (Continued from page 1) d. Visitation/Parenting Time (You must file a sworn to Financial Affidavit (JD-FM-6) at least 5 days before the hearing. You must also file an Affidavit Concerning Children (JD-FM-164) and a completed Worksheet for the Connecticut Child Support and Arrearage Guidelines (CCSG-1, JD-FM-220) on your hearing date). e. Other (Please be specific): Modify visitation (parenting time) as follows: Signature Address (Number, street, city, state, zip code) Print Name Title (If applicable) Date Signed Telephone (Area code first) Certification to all attorneys I certify that a copy of this document was mailed or delivered electronically or non-electronically on (date) and self-represented parties of record and that written consent for electronic delivery was received from all attorneys and self-represented parties receiving electronic delivery. Name and address of each party and attorney that copy was mailed or delivered to* *If necessary, attach additional sheet or sheets with name and address which the copy was mailed or delivered to. Signed (Signature of filer) Print or type name of person signing Date signed X Mailing address (Number, street, town, state and zip code) Telephone number Order For Hearing and Summons (To be completed by clerk or support enforcement officer, if applicable) The Court orders that a hearing be held at the time and place shown below. The Court also orders the Plaintiff Defendant Support Enforcement Officer to give notice to the opposing party of the Motion and of the time and place where the court will hear it, by having a true and attested copy of the Motion and this Order served on the opposing party by any proper officer at least 12 days before the date of the hearing. Proof of service must be made to this Court at least 6 days before the date of hearing. Superior Court, Judicial District of Date Hearing to T be held at Court Address Room Number Time To any proper officer: By the Authority of the State of Connecticut, you must serve a true and attested copy of the above Motion and Order For Hearing and Summons on the person named below in one of the ways required by law at least 12 days before the date of the hearing, and file proof of service with this Court at least 6 days before the hearing. Person to be Served Address By the Court Assistant Clerk/Su