JD-FM-199 Rev. 3-14
C.G.S. Sec. 46b-56a
1) The physical residence of the child(ren) will be according to the following schedule:
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.
STATE OF CONNECTICUT
Signature of party
It is proposed that:
2) Decision-making about the child(ren)'s health, education and religious upbringing will be allocated to the parent(s) as
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
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:
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 attorney (if applicable)
Judicial District of
Plaintiff's name (Last, First, Middle Initial) Defendant's name (Last, First, Middle Initial)
Date signed Date signed
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.
Signed (Signature of filer)
I certify that a copy of this document was mailed or delivered electronically or non-electronically on (date)
to all attorneys
Name and address of each party and attorney that copy was mailed or delivered to*
Print or type name of person signing
Mailing address (Number, street, town, state and zip code)
*If necessary, attach additional sheet or sheets with name and address which the copy was mailed or delivered to.
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.