STATE OF CONNECTICUT SUPERIOR COURT REQUEST FOR LEAVE JD-FM-202 Rev. 8-07 P.B. Sec. 25-26 INSTRUCTIONS TO PREPARER 1. If you would like to file a motion for modification and have been ordered to attach a request for leave, complete Sections I, II and III and attach your motion for modification to this form. 2. Have this form served with the attached motion for modification on the opposing party and return it to the court. 3. If you are representing yourself and the other party does not have an appearance in this case, bring this form to court clerk's office for completion of Section III.B. 1. If you choose to object to this Request for Leave, complete Sections IV and V on page 2. 2. Provide a copy to the other party and return this form to the court. www.jud.ct.gov TO CLERK TO RESPONDING PARTY JUDICIAL DISTRICT OF AT (Address of court) 1. Send notice to all appearing parties of the court's order regarding this request. 2. If Request for Leave is granted, upon receipt of filing fee for the motion for modification, assign hearing date if necessary and retain a copy for court file. DOCKET NO. PLAINTIFF'S NAME (Last, first, middle initial) DEFENDANT'S NAME (Last, first, middle initial) SECTION I—REQUEST FOR LEAVE (PERMISSION) TO FILE 1. I am the PLAINTIFF motion for modification. DEFENDANT in this case and I am requesting leave (permission) to file the attached 2. In the attached motion, I am requesting modification of the (Check all that apply): FOR COURT USE ONLY Final order for custody that is dated: * R E Q M O D * Final order for visitation that is dated: TYPE OR PRINT NAME OF PERSON SIGNING SIGNED (Attorney or Pro Se Party) ADDRESS (No., street, town or city, state and zip code) DATE SIGNED TELEPHONE NO. (Area code first) SECTION II — SWORN STATEMENT I certify that the factual and legal basis for the modification is true and accurate to the best of my knowledge and belief. SIGNED (Moving party or other person having personal knowledge of the facts recited in the motion for modification) X Subscribed and sworn to before me on: DATE SIGNED (Notary, Comm. of Superior Court, Assistant Clerk) SECTION III — NOTICE (Check either A or B below) A - CERTIFICATION (Check and complete if responding party has an appearance on file.) I certify that I mailed or delivered a copy of this request to: NAME DATE MAILED/DELIVERED ADDRESS (No., street, town or city, state and zip code)* SIGNED (Attorney or Pro Se Party) TYPE OR PRINT NAME OF PERSON SIGNING DATE SIGNED *If necessary, attach additional sheet with name of each party served and the address at which service was made. B - INSTRUCTION TO PROPER OFFICER (Check and complete if responding party does not have an appearance on file.) TO ANY PROPER OFFICER: By the Authority of the State of Connecticut, you must serve a true and attested copy of the above Request on the below named person in one of the ways required by law and file proof of service with this court. NAME OF PERSON TO BE SERVED ADDRESS SIGNED (Assistant Clerk, Comm. Sup. Ct.) DATE SIGNED NOTICE OF RIGHT TO OBJECT AND APPEAR If you do not file an objection to this Request for Leave within ten days of the date of service of this request, the request may be determined by the court with or without hearing. To object, fill out Sections IV and V on page 2 of this form, provide a copy to any pro se party and/or attorney who has filed an appearance in this case, and return this form to the court clerk's office prior to expiration of the ten day period. If you do not file an objection or an Appearance in this case, you may not receive notice of the scheduling of a hearing, if any, and the Request for Leave may be granted. Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com DEFENDANT'S NAME (Last, first, middle initial) PLAINTIFF'S NAME (Last, first, middle initial) DOCKET NO. SECTION IV — OBJECTION AND APPEARANCE BY RESPONDING PARTY FOR COURT USE ONLY I hereby object to the filing of the attached motion for modification for the following reason(s): * O B J E C T * Enter the appearance of: NAME OF ATTORNEY, LAW FIRM OR PRO SE PARTY JURIS NO. (If attorney or law firm) ADDRESS OF ATTORNEY, LAW FIRM OR PRO SE PARTY TELEPHONE NO. (Area code first) SIGNED (Attorney or Pro Se Party) DATE SIGNED SECTION V — CERTIFICATION BY RESPONDING PARTY I certify that I mailed or delivered a copy of this objection to: NAME DATE MAILED/DELIVERED ADDRESS (No., street, town or city, state and zip code)* SIGNED (Attorney or Pro Se Party) DATE SIGNED TYPE OR PRINT NAME OF PERSON SIGNING *If necessary, use the space below to list the name of each party served and the address at which service was made. SECTION VI — COURT ORDER The request for leave is GRANTED. The request for leave is DENIED. It is hereby ORDERED THAT: BY THE COURT JD-FM-202 (back/page 2) Rev. 8-07 DATE OF ORDER Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com