‘‘‘‘‘‘‘‘‘‘‘‘‘‘‘‘‘‘‘‘‘‘‘‘‘‘‘‘DOCKET NO: (Case #)     :                  SUPERIOR COURT

(Names of plaintiffs)                                         :                      JUDICIAL DISTRICT OF

                                                                                :                  (See court papers)

5.                                                                     :                 AT (City where court is)

(Name of defendant - your name)             :                  Date: (date you are filing this petition)

Petition for Appeal of Decision of Family Support Magistrate

To the Superior Court, Judicial District of (see above) at (city where court is) comes the defendant, (your name) , who, pursuant to C.G.S. ' 46b-231(n) and Connecticut Practice Book ' 25-66, hereby appeals from the decision of Family Support Magistrate, (name of magistrate who made order you disagree with) , which was entered on (date of order you disagree with), ordering child support. Plaintiff/defendant respectfully represents that: (fill in all of the blanks that apply to your case)

1. On (date of order you disagree with) , the Court ordered him/her to pay child support in the amount of $ (see your order) /per week in current support and

$ (amount of weekly arrearage payment) /per week as weekly payment toward the an arrearage.

                    2. At trial, the defendant offered the following evidence about his/her ability to pay child support: (Check all of the choices that apply)

    (x)    a.  Pay stub(s) from employment showing gross earnings of (earnings on the pay stubs you gave to the court) per week

    (x)    b.  Proof of receipt of SSI

    (x)    c.  Proof of receipt of Temporary Family Assistance (TFA), State Administered General Assistance (SAGA), or other public assitance.

    (x)    d. Appellant= s financial affidavit dated (date of the financial affidavit you gave to court), showing gross weekly earnings of $ (amount of your weekly earnings on your financial affidavit) per week.

    (x)    e. Testimony from the appellant concerning his/her ability to pay child support.

    (x)    f. Other evidence: (may include tax returns, doctors letters, etc.)

3. The decision violates Conn. Gen . Stat. 46b-215b. It deviates from the presumptive guideline amount without adequate findings or evidence to justify a deviation.

4. Substantial rights of the appellant have been prejudiced because the decision of the family support magistrate is:

1. In violation of constitutional or statutory provisions
2. In excess of the statutory authority of the family support magistrate
3. Made upon unlawful procedure
4. Affected by other error of law
5. Clearly erroneous in view of the reliable, probative and substantial evidence on the whole record; or
6. Arbitrary or capricious or characterized by abuse of discretion or clearly unwarranted exercise of discretion.

                                                                                    RESPONDENT

                                                                                    (Sign here)

                                                                                    Name: (Print your name here)

                                                                                    Address: (Print your address)

                                                                                    Telephone Number: (Yours)

CERTIFICATION

I hereby certify that a copy of the above was mailed/delivered to the following parties of record on (date you mailed or delivered copies of this petition to the people listed below):

Office of Attorney General

Child Support Department

55 Elm Street.

Hartford, CT 06106

(Sign here)