PROPOSED PARENTAL RESPONSIBILITY PLAN JD-FM-199 Rev. 3-14 C.G.S. Sec. 46b-56a STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov 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. Docket number Instructions If there is a dispute in Superior Court between the parents about the child (ren)'s custody, care, education and upbringing, this form must be completed and filed with the court on or before the case management date, if applicable, or, as otherwise ordered by the court. Attach additional sheets if necessary. Judicial District of At (Town) ADA NOTICE Plaintiff's name (Last, First, Middle Initial) Defendant's name (Last, First, Middle Initial) It is proposed that: 1) The physical residence of the child(ren) will be according to the following schedule: 2) Decision-making about the child(ren)'s health, education and religious upbringing will be allocated to the parent(s) as follows: 3) Future disputes between the parents will be resolved in the following manner (include, where appropriate, the involvement of a mental health professional or other parties to help reach a developmentally appropriate resolution to such disputes): 4) Failure of either parent to honor his or her responsibilities under the plan will be dealt with in the following manner: 5) The changing needs of the child(ren) as the child(ren) grow and mature will be dealt with in the following manner: 6) Other: The child(ren)'s exposure to harmful parental conflict will be minimized; the parents will, in appropriate circumstances, meet their responsibilities through agreements; and both parents will protect the best interests of the child(ren). Signature of party Date signed Signature of attorney (if applicable) Date signed X X 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 Telephone number X Mailing address (Number, street, town, state and zip code) American LegalNet, Inc. www.FormsWorkFlow.com