Fillable Connecticut superior court CUSTODY/VISITATION AGREEMENT form

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Connecticut superior court CUSTODY/VISITATION AGREEMENT form

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BROWSE STATE OF CONNECTICUT/DEPARTMENT OF ADMINISTRATIVE SERVICES (CT) FORMS

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1. The custody of the child(ren) shall be as follows:
CUSTODY/VISITATION AGREEMENT STATE OF CONNECTICUT
SUPERIOR COURT
www.jud.ct.gov
JD-FM-183 Rev. 7-17
C.G.S. § 46b-66
2. As to visitation with the child(ren):
Holiday and school vacation visits:
Legal Custody:
Primary Residence:
The parties agree that:
Who will pick up/drop off for visits:
Instructions Complete form. Make copies for yourselves and give the original to the court clerk.
Judicial District of
At (Town )
Docket number
Plaintiff's name (Last, first, middle initial) Defendant's name (Last, first, middle initial)
*AGREMNT*
AGREMNT
Court Use Only
Name of child (Last, First, Middle Initial)
Date of birth
Name of child (Last, First, Middle Initial)
Date of birth
4. As to post-majority educational support ("X" one):
No post-majority educational support order is requested at this time; or
The parties ask the Court to reserve jurisdiction to determine whether a post-majority educational support order
should issue and the terms of the order; or
The parties ask the Court to enter post-majority education support as follows (Attach additional sheets if necessary):
The parties ask the Court to find that it is more likely than not that the parents would have provided post-majority
educational support, and for the Court to reserve jurisdiction to determine whether to enter an educational support
order and the terms of the order; or
3. As to income withholding, we understand that the support orders are by immediate income withholding unless for
cause or we both agree to it being contingent: We agree to a(n)
income withholding.
ContingentImmediate
Continued on Back/Page 2
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Date
7. As to child care costs:
JD-FM-183 (Back/Page 2) Rev. 7-17
8. Other
6. As to health insurance and unreimbursed medical costs:
This amount follows
the Guidelines
This amount is different from the Guidelines (deviation)
Give reasons for deviation from the Guidelines (See Guidelines for reason that applies)
This amount follows
the Guidelines
This amount is different from the Guidelines (deviation)
Give reasons for deviation from the Guidelines (See Guidelines for reason that applies)
Signed (Plaintiff/Plaintiff's attorney)
Date
We hereby certify that the above conforms with the agreement of the parties.
Date
Signed (Defendant/Defendant's attorney)
Signed (Guardian ad Litem/Attorney for the Minor Child)
Date
Approved and so ordered (Judge/Family Support Magistrate)
This amount follows
the Guidelines
5. As to current and/or past due child support:
This amount is different from the Guidelines (deviation)
Give reasons for deviation from the Guidelines (See Guidelines for reason that applies)
The amounts/percentages indicated below for Child Support, Health Care Insurance Coverage, Unreimbursed Health Care
Costs, and Child Care Costs must follow the Child Support and Arrearage Guidelines (the Guidelines), unless you meet one
of the deviation criteria in the Guidelines (reasons for an amount different than the Guidelines). The Guidelines are available at
any Judicial District Clerk's Office, the Court Service Centers, and on the Judicial Branch web site -
www.jud.ct.gov.
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Connecticut superior court CUSTODYVISITATION AGREEMENT form

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Completed 2 April 2020

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