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APPEAL FROM FAMILY SUPPORT MAGISTRATE

JD-FM-111 REV. 11-01

C.G.S. 46b-231(n)

STATE OF CONNECTICUT

SUPERIOR COURT

www.jud.state.us

INSTRUCTIONS TO APPELLANT

1. Type or print legibly; sign the certification section.

2. Prepare a separate petition which includes the reasons for the appeal and attach the petition to this form.

3. Serve a copy of this form with the petition attached, to each party of record, and mail one copy, certified mail, to the following address; OFFICE OF ATTORNEY GENERAL, CHILD SUPPORT DEPARTMENT, 55 ELM ST., HARTFORD, CT 06106

4. File this form, with the petition attached, with the clerk of the court for the Judicial District where the magistrate= s decision was rendered WITHIN FOURTEEN DAYS OF EITHER:

a. the date the final decision of the magistrate was filed with the clerk, OR

b. if a rehearing was requested, the date of filing the notice of the decision thereon, WHICHEVER IS LATER.

NAME OF CASE

DOCKET NO.

NAME AND ADDRESS OF COURT

NAME OF MAGISTRATE

FILING DATE OF MAGISTRATE= S DECISION

FILING DATE OF DECISION ON REQUEST FOR REHEARING (If Applicable)

ATTORNEYS OR PRO SE PARTY(IES) AT MAGISTRATE HEARING º

FOR PLAINTIFF (indlude Juris No. if applicable)

FOR RESPONDENT (indlude Juris No. if applicable)

TRANSCRIPT:

9 NOT NECESSARY 9 HAS BEEN ORDERED

ADDITIONAL EVIDENCE REQUESTED:

9 NO 9 YES -If yes, attach statement pursuant to C.G.S. 46b-231(n)(5)

NOTICE

The filing of an appeal from a decision of a Family Support Magistrate does not affect the order of support of a Family Support Magistrate, but it shall continue in effect until the appeal is decided, and thereafter, unless denied, until changed by further order of a Family Support Magistrate or the Superior Court. Further, any order entered by the court pursuant to an appeal under C.G.S. 46b-231(n) may be retroactive to the date of the original order entered by the Family Support Magistrate.

(Signature of attorney or pro se party)

APPEAL BY:

TELEPHONE NO.

JURIS NO. (If applicable)

CERTIFICATION

I hereby certify that a copy of the above was mailed/delivered to:

NAME OF EACH PARTY SERVED*

ADDRESS AT WHICH SERVICE WAS MADE*

* If necessary, attach additional sheet with name of each party served and the address at which service was made.

I further certify that a copy was mailed, certified mail, to the office of the Attorney General

at the address shown in instruction #2 above in accordance with C.G.S. ' 46(b)-231(n)(2).

COURT USE ONLY

FILE DATE

SIGNED (Individual attorney or pro se party)

DATE COPY(IES) MAILED OR DELIVERED

NAME OF CASE				DOCKET NO.
NAME AND ADDRESS OF COURT				NAME OF MAGISTRATE
FILING DATE OF MAGISTRATE= S DECISION			FILING DATE OF DECISION ON REQUEST FOR REHEARING (If Applicable)
ATTORNEYS OR PRO SE PARTY(IES) AT MAGISTRATE HEARING º	FOR PLAINTIFF (indlude Juris No. if applicable)			FOR RESPONDENT (indlude Juris No. if applicable)
TRANSCRIPT: 9 NOT NECESSARY 9 HAS BEEN ORDERED		ADDITIONAL EVIDENCE REQUESTED: 9 NO 9 YES -If yes, attach statement pursuant to C.G.S. 46b-231(n)(5)

(Signature of attorney or pro se party) APPEAL BY:		TELEPHONE NO.	JURIS NO. (If applicable)
CERTIFICATION
I hereby certify that a copy of the above was mailed/delivered to:
NAME OF EACH PARTY SERVED*	ADDRESS AT WHICH SERVICE WAS MADE*

* If necessary, attach additional sheet with name of each party served and the address at which service was made. I further certify that a copy was mailed, certified mail, to the office of the Attorney General at the address shown in instruction #2 above in accordance with C.G.S. ' 46(b)-231(n)(2).		COURT USE ONLY
		FILE DATE
SIGNED (Individual attorney or pro se party)	DATE COPY(IES) MAILED OR DELIVERED