How to Fill Out Certificate of Compliance (JD-FM-175)

The Certificate of Notice in Family Cases (Public Assistance), form JD-FM-175, is a mandatory document in Connecticut divorce, legal separation, or custody cases where either spouse or their minor children have ever received public assistance. Public assistance includes benefits like HUSKY (Medicaid), Temporary Family Assistance (TFA), or other forms of state or city aid. The purpose of this form is to certify to the court that you have officially notified the Connecticut Attorney General (for state aid) or the relevant Town/City Clerk (for local aid) about your case. This notification is required by law (C.G.S. § 46b-55) and allows the state or town to protect its financial interest, primarily by ensuring that any child support orders consider the aid that has been provided.

This form is typically filed at the very beginning of your case, along with your initial divorce complaint or custody application. It serves as your sworn statement that you have sent copies of your initial court filings to the correct government agency. Failing to file this form when required can delay your case, as the court cannot enter final orders for child support or alimony without this certification. It is a crucial step in ensuring your case complies with state procedures and proceeds smoothly.

Requirements

Before you begin filling out this form, you must first complete a critical action step and gather the necessary information. You will need:

• Confirmation of Public Assistance: You must know if you, your spouse, or your children have ever received public assistance from the State of Connecticut (e.g., HUSKY, TFA) or any specific Connecticut town or city.
• Copies of Your Initial Court Documents: You must have copies of all the documents you are filing to start your case. The specific documents are listed in the checklist on form JD-FM-175 and may include:
  • Summons (JD-FM-3)
  • Complaint/Petition (e.g., Divorce Complaint, JD-FM-159)
  • Notice of Automatic Court Orders (JD-FM-158)
  • Affidavit Concerning Children (UC-101)
  • Custody/Visitation Application (JD-FM-164)
  • Financial Affidavit (JD-FM-6-SHORT or JD-FM-6-LONG)
  • State Marshal's Return of Service
• Proof of Delivery: You must have already mailed or hand-delivered the copies of your initial court documents to the appropriate agency.
  • For state assistance: Office of the Attorney General, 165 Capitol Avenue, Hartford, CT 06106.
  • For town/city assistance: The office of the Town or City Clerk for the municipality that provided the aid.
• Date of Delivery: The exact date you mailed or delivered the documents.
• Case Information: Your case name, the Judicial District and court location, and the Return Date from your Summons (JD-FM-3).

Step-by-Step Instructions

Case Information

This top section of the form identifies your case for the court clerk. The information should match what is on your Summons (JD-FM-3) and Complaint (JD-FM-159).

Judicial District of: Enter the name of the Judicial District where you are filing your divorce or custody case. For example, 'Hartford', 'New Haven', or 'Stamford/Norwalk'. Example: Fairfield

At (Town): Enter the town where the specific courthouse is located. For example, if you are in the Fairfield Judicial District, you might be filing at the courthouse in Bridgeport. Example: Bridgeport

Return date (Month, day, year) (if applicable): Enter the Return Date exactly as it appears on your Summons (form JD-FM-3). This is a specific date, usually a Tuesday, that you select when you start the case. It sets the deadline for your spouse to respond. Example: October 22, 2024 ⚠️ If you are filing a non-adversarial (uncontested) divorce using a Joint Petition, you may not have a Return Date. In that case, you can leave this field blank.

Name of case: Write the full name of the case, with the Plaintiff (person filing) first and the Defendant second. This must match your other court documents. Example: Jane A. Doe v. John B. Doe

Docket number (If known): If the court has already assigned a docket number to your case, enter it here. If you are filing this form with your very first set of papers, you will not have a docket number yet, so you can leave this blank. Example: FBT-FA24-1234567-S

Certification and Mailing Details

This is the core of the form. Here, you will certify which documents you sent, when you sent them, and to which government agency. You must complete the mailing before you fill out this section.

This is to certify that a true copy of the:: Check the box next to every document that you mailed or delivered to the Attorney General or Town Clerk. You should be sending a copy of every document you are filing with the court to start your case. Example: If you are starting a standard divorce with children, you would likely check 'Summons', 'Complaint', 'Notice of Automatic Court Orders', 'Affidavit Concerning Children', and 'Financial Affidavit'. ⚠️ Only check the boxes for documents you actually sent. This is a sworn statement to the court.

was mailed or delivered on (month, day, year): Enter the full date that you placed the documents in the mail or hand-delivered them to the government office. Example: September 30, 2024 ⚠️ Do not date this for the future. You must have already sent the documents before signing and filing this form.

to: (check all that apply): Check the box indicating where you sent the documents. You may need to check both boxes if assistance was received from both the state and a specific town.

If any party or any child received public assistance from the State of Connecticut:: Check this box if you, your spouse, or your children ever received state-level benefits. This includes HUSKY Health (Medicaid/CHIP), Temporary Family Assistance (TFA), or State-Administered General Assistance (SAGA). The form provides the correct mailing address for the Attorney General's Office.

If any party or any child received public assistance from any town or city in the State of Connecticut:: Check this box if assistance was provided by a specific municipality (e.g., local welfare or housing aid). On the lines provided, write the full name and address of the City or Town Clerk's office for the town that provided the aid. You may need to look this up on the town's official website. Example: The City Clerk for the town providing public assistance: Town Clerk's Office 123 Main Street Anytown, CT 06123 ⚠️ This must be the clerk for the town that provided the assistance, which may not be the town where you currently live.

Signature and Contact Information

The final section is where you sign the form, certifying that all the information you have provided is true and accurate.

Signature: Sign your name in ink. Your signature certifies that you have complied with the notice requirements as stated on the form. ⚠️ An unsigned form is invalid and will be rejected by the court clerk.

Print name: Clearly print your full legal name. Example: Jane A. Doe

Address (Number, street, town, state, zip code): Enter your current complete mailing address. Example: 456 Oak Avenue, Fairfield, CT 06824

Telephone number (Area code first): Enter a phone number where you can be reached during the day. Example: (203) 555-1234

Common Mistakes to Avoid

1. Filing Before Mailing: A common error is filling out and filing this form before actually mailing the required documents to the Attorney General or Town Clerk. You must send the documents first, then certify that you have done so.
2. Forgetting to File the Form: Some people mail the documents to the Attorney General but then forget to complete and file form JD-FM-175 with the court. The court has no way of knowing you complied without this certification.
3. Ignoring the Requirement: Not filing the form at all when public assistance was received. This will halt your case, as a judge cannot grant your divorce without it.
4. Incorrect Recipient: Sending the notice to the Attorney General for town-level aid, or to a Town Clerk for state-level aid. State aid (HUSKY, TFA) requires notice to the Attorney General; local aid requires notice to the specific town that provided it.
5. Incomplete Checklists: Forgetting to check off all the documents that were included in the mailing packet. Review the checklist carefully to ensure it's accurate.
6. Missing Signature: Submitting an unsigned form. The court will reject it, causing delays.

Frequently Asked Questions

What exactly is considered 'public assistance' in Connecticut? Public assistance is a broad term. For the purposes of this form, it primarily includes benefits administered by the Department of Social Services (DSS). Key examples are HUSKY A, B, C, or D (Medicaid/CHIP), Temporary Family Assistance (TFA), and cash assistance like State-Administered General Assistance (SAGA). It can also include state-funded childcare or assistance from a specific town or city's welfare department.

What if I'm not sure if my spouse or I ever received public assistance? If you are uncertain, it is always safer to provide the notice. You can contact the Connecticut Department of Social Services (DSS) to inquire about any state assistance history. If you suspect your spouse received aid but you can't confirm, you should still send the notice to the Attorney General out of an abundance of caution to prevent delays in your case. State on the form that you believe assistance may have been received.

Do I need to file this form for an uncontested (nonadversarial) divorce? Yes. The requirement to notify the state is based on the receipt of public assistance, not on whether the divorce is contested or uncontested. If you are filing a Joint Petition for a nonadversarial divorce and public aid was received, you must still send the required documents (including the Joint Petition) to the Attorney General/Town Clerk and file form JD-FM-175 with the court.

My children received HUSKY, but my spouse and I never did. Do I still need to file this? Yes. The law (C.G.S. § 46b-55) and the form itself are clear that the requirement applies if 'you, your spouse, or your children have ever received public assistance.' Since HUSKY is state assistance, you must notify the Attorney General and file this certification.

The form says I don't need to file it if my case is 'only about visitation.' What does that mean? This exception applies to very limited cases, typically post-divorce, where the only issue being brought before the court is a modification of the parenting/visitation schedule and does not involve any financial matters like child support or alimony. If your case involves divorce, legal separation, or establishing/modifying child support, this exception does not apply to you.

Next Steps

After you have completed and signed the JD-FM-175 form:

1. Make Copies: Make at least two copies of the signed form. One copy is for your personal records, and the other will be part of the packet you serve on your spouse.
2. Assemble Your Filing Packet: This form does not get filed by itself. It should be included with the original set of documents you are filing with the court to start your case. This packet will typically include the original Summons, Complaint, Affidavit Concerning Children, etc.
3. File with the Court: Take your complete, original filing packet (including the signed JD-FM-175) to the Superior Court Clerk's office in the Judicial District you listed on the form. You will need to pay a court filing fee or have an approved Application for Waiver of Fees (JD-FM-75).
4. Serve Your Spouse: After the clerk accepts your papers and signs the Summons, you must have the entire packet (including a copy of this JD-FM-175) officially served on your spouse by a State Marshal.

The court will review this certification to ensure compliance. Once confirmed, your case can proceed toward orders for support and, eventually, a final judgment.