FOR COURT USE ONLY
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:
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.
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.
Section 4 - Participation Results (To be completed by Family Services)
Section 3 - Completion Certificate (To be completed by Service Provider)
"X" if applicable
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
SUPERIOR COURT
www.jud.ct.gov
Instructions — Press Hard, you are making 4 copies.
Section 1 - Court Order/Family Support Magistrate Order (To be completed by Clerk)
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:
appropriate fee for participating in a parenting
education program.
Signed (Judge, FSM, Assistant Clerk)
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:
To: The Superior Court
The Court Support Services Division, Family Services Unit of the Superior Court certifies the results of participation as indicated above.
Signed (Authorized Family Division Person)
Signed (Authorized Person)
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.
Section 2 - Participant Information (To be completed by Participant - print or type)
OR
OR
(Select One)
(Select One)
ORDPEP (Order for participation)
FNOPEPF (Finding of inability to pay)
CERTPEP (Certification of results)
Court Location
Name of case (Plaintiff vs. Defendant)
Docket number
Name of participant (Person taking part in the program)
Court Order Family Support Magistrate Order
Is Able to pay directly to the service provider the Is Indigent or Unable to pay to take part in a parenting
By the Court/Family Support Magistrate Division (Print or type name of Judge/FSM)
Date Ordered
Name and address of participant (Number, street, town and zip code)
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 Connect-
Name of Service Provider
Date(s) of Participation Location at Which Program Was Provided
satisfactorily completed the program. did not satisfactorily complete the program for the following reason(s): lack of attendance
other (specify):
Print or Type Name of Person Signing at Left Date Signed
Print or Type Name of Person Signing at Left Date Signed
icut Practice Book).
