PARENTING EDUCATION PROGRAM - ORDER, CERTIFICATE AND RESULTS JD-FM-149 Rev. 11-12 C.G.S. §§ 46b-1, 46b-56, 46b-69b, 46b-231(m)(12) STATE OF CONNECTICUT FOR COURT USE ONLY ORDPEP (Order for participation) FNOPEPF (Finding of inability to pay) CERTPEP (Certification of results) Court Location SUPERIOR COURT www.jud.ct.gov Instructions -- Press Hard, you are making 4 copies. To person taking part in the program: 1. Provide name of case and docket number if available in designated boxes. 2. Complete Section 2 if you are attending the Program to comply with the Automatic Orders or to comply with an order of the court or family support magistrate. 3. If you believe you are unable to pay or indigent, complete and submit form JD-FM-75, Application for Waiver of Fees/Appointment of Counsel Family before attending the program. 4. YOU MUST bring this form and any approved Fee Waiver form to the service provider. 5. Select a service provider from a list available at the clerk's office and contact that provider to arrange attendance and to tell it the name of any person that you do not want to be with in the same program. 6. Give the original and ALL copies of the form to the service provider. Name of case (Plaintiff vs. Defendant) To Clerk: 1. If program participation is ordered by the court or family support magistrate, enter court location above and docket number and complete section 1. 2. Keep gold copy and give original and remaining copies to participant. To Service Provider: 1. Complete Section 3 and return original and green copy to the appropriate Family Division Office. 2. Give/send pink copy to participant. 3. Keep yellow copy for your records. To Family Services: 1. Upon receipt of Completion Certificate from service provider, complete section 4 and forward original to the superior court listed. 2. Keep green copy for your records. Docket number Section 1 - Court Order/Family Support Magistrate Order Name of participant (Person taking part in the program) (To be completed by Clerk) (Select One) Court Order OR The participant named above has been ordered to take part in a parenting education program established under Section 46b-69b of the Connecticut General Statutes. The court finds that this individual: (Select One) Is Able to pay directly to the service provider the OR appropriate fee for participating in a parenting education program. By the Court/Family Support Magistrate Division (Print or type name of Judge/FSM) Family Support Magistrate Order All parties being present before the Family Support Magistrate Division, it is ordered that the participant named above take part in a parenting education program established under Section 46b-69b of the Connecticut General Statutes. It is found that participation is necessary and that this individual: Is Indigent or Unable to pay to take part in a parenting education program and all costs for participation in a program shall be covered by the service provider under the provisions of Section 46b-69b of the Connecticut General Statutes. Signed (Judge, FSM, Assistant Clerk) Date Ordered Section 2 - Participant Information (To be completed by Participant - print or type) Name and address of participant (Number, street, town and zip code) "X" if applicable I request not to be assigned to the same group as: (Name of person) "X" this box if you are attending the parenting education program to comply with the Automatic Orders (Section 25-5 of the Connecticut Practice Book). Section 3 - Completion Certificate Name of Service Provider Date(s) of Participation (To be completed by Service Provider) Location at Which Program Was Provided To: The Court Support Services Division, Family Services Unit of the Superior Court The participant named above was scheduled to participate in our Parenting Education Program. It is certified that the participant: satisfactorily completed the program. other (specify): Signed (Authorized Person) Print or Type Name of Person Signing at Left Date Signed did not satisfactorily complete the program for the following reason(s): lack of attendance Section 4 - Participation Results Signed (Authorized Family Division Person) (To be completed by Family Services) To: The Superior Court The Court Support Services Division, Family Services Unit of the Superior Court certifies the results of participation as indicated above. Print or Type Name of Person Signing at Left Date Signed American LegalNet, Inc. www.FormsWorkFlow.com