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.

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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

(PUBLIC ASSISTANCE)

JD-FM-175 Rev. 1-2001

P.B. §§ 10-12 through 10-17,

25-2

C.G.S. § 46b-55

SIGNATURE

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)

CERTPA

COURT USE ONLY

TELEPHONE NO. (Area code first)

INSTRUCTIONS

(CHECK ALL THAT APPLY)

This is to certify that a true copy of the:

Summons

Complaint

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)

Financial Affidavit

to:

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.

www.jud.ct.gov

STATE OF CONNECTICUT

SUPERIOR COURT

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