Fillable Connecticut STATEMENT OF FACTS CONCERNING CHILDREN form

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Connecticut STATEMENT OF FACTS CONCERNING CHILDREN form

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U.S.A. forms for State of Connecticut/Department of Administrative Services

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STATEMENT OF FACTS
CONCERNING CHILDREN
JD-FM-164CO New 4-20
C.G.S. § 46b-115s; P.B. § 25-57; E.O. 7T
STATE OF CONNECTICUT
SUPERIOR COURT
COURT OF PROBATE
www.jud.ct.gov
You must provide information about the past five years for each child affected by this case. Provide the information below.
If you need more space, use form JD-FM-164A.
To The present
To
Place of residence
(Town or city, and state, unless
confidential by court order)
Name(s) and present address(es) of
person(s) child lived with
(unless confidential)
Relationship
to child
To
To
To
Page 1 of 2
Instructions: Fill out this form completely. Your statement must be true to the best of your knowledge and made under the penalty of false statement.
Date(s) of residence
AFFACUS
Court Use Only
Judicial District of
At (Town)
Probate District name and number Docket number
Plaintiff/Applicant's (Last, first, middle initial) Defendant/Respondent's (Last, first, middle initial)
Child's name (First, middle, last) Date of birth (Month, day, year)
(date)
(date)
(date)
(date)
(date)
Child's name (First, middle, last) Date of birth (Month, day, year)
Residence information is same as for child above.
(If not same, provide information)
Check here if additional children are listed on JD-FM-164A.
To The present
To
Place of residence
(Town or city, and state, unless
confidential by court order)
Name(s) and present address(es) of
person(s) child lived with
(unless confidential)
Relationship
to child
To
To
To
Date(s) of residence
(date)
(date) (date)
(date) (date)
(date) (date)
(date) (date)
From
From
From
From
From
From
From
From
From
From
(date)
(date)
(date)
(date)
*AFFACUS*
Note: Use this form only if you are filing an Application for Relief from Abuse (form JD-FM-137CO).
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5. The mother of the child(ren) named in the Complaint or Application is pregnant.
6. A child has been born to the mother named in the Complaint or Application after the filing of the Complaint or Application.
No one except the plaintiff/applicant and defendant/respondent has physical custody
or claims to have custody or visitation rights regarding any child listed here.
The following person(s) has physical custody or claims to have custody or visitation rights
regarding any child listed here:
I do not know of other civil or criminal cases in Connecticut or another state, now or in the past, that could affect the
current case, including enforcement cases and family violence, protective order, termination of parental rights and
adoption cases.
1. (Select one)
been involved as a party or a witness or in any other capacity in a case or cases
in Connecticut or in another state concerning custody of or visitation with any child listed in this Statement of Facts. If you
checked "I have," give the name of the court, the court case number and the date of the decision in the case or cases:
JD-FM-164CO New 4-20
You must tell the court about any case in Connecticut or
another state that could affect this case, if you learn about
it during this case.
(Select item 2 or 3 below)
4. (Select one)
I know of the following civil or criminal cases, in Connecticut or another state, now or in the past, that could affect the
current case, including enforcement cases and family violence, protective order, termination of parental rights and
adoption cases.
(unless confidential)
I have I have not
2.
3.
Case name
Docket number
Court location (Including state)
Nature of proceeding
Case name Docket number
Court location (Including state)
Nature of proceeding
Name:
Address:
Yes No Do not know
Yes No Do not know If yes, fill in the following:
Child's name
Date of birth (Month, day, year)
Page 2 of 2
ADA NOTICE
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.
Date signedEnter your name as your signature
The representations made in this document are
made under the penalty of false statement.
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Connecticut STATEMENT OF FACTS CONCERNING CHILDREN form

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Completed 12 April 2020

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