Certification of Public Assistance Form
Certification of Public Assistance.pdf This form is used to notify State and local agencies that you are filing for divorce in Connecticut.
If any party or any child received public assistance from the State of Connecticut:
The Office of the Attorney General
55 Elm Street
Hartford, CT 06106
If any party or any child received public assistance from any town or city
in the State of Connecticut:
The City Clerk for the town providing public assistance:
JUDICIAL DISTRICT OF AT (Town)
DOCKET NO. (If known)
CERTIFICATION OF NOTICE
IN FAMILY CASES
JD-FM-175 Rev. 1-2001
P.B. §§ 10-12 through 10-17,
C.G.S. § 46b-55
And State Marshal’s return was mailed/delivered on (month, day, year)
NAME OF CASE
RETURN DATE (Mo., day, year) (if applicable)
(No., street, town)
ADDRESS (No., street, town, state, zip code)
COURT USE ONLY
TELEPHONE NO. (Area code first)
(CHECK ALL THAT APPLY)
This is to certify that a true copy of the:
Custody Application (only if seeking child support)
Notice of Automatic Court Orders
Order to Attend Hearing (for custody actions seeking support)
Affidavit Concerning Children (for proceedings seeking custody)
If you, your spouse, or your children have ever received public assistance (state aid, city aid, or
welfare) follow the instructions below (visitation actions are exempt from these requirements):
1. Mail or deliver a copy of the Summons and Complaint or Custody Application, Notice of
Automatic Court Orders, Order to Attend Hearing (if applicable), and a copy of the State Marshal’s
return (proof that the court papers were served) to the Attorney General or Town Clerk’s office.
2. Complete the form below.
3. Keep a copy for your records.
4. File this Certification form with the court clerk when you file your Summons and Complaint
or Custody Application.
STATE OF CONNECTICUT