Conn. Practice Book Form 212

The undersigned, on behalf of the Defendant, hereby propounds the following interrogatories to be

answered by the Plaintiff, ____________, under oath, within sixty (60) days of the filing hereof in

compliance with Practice Book Section 13-2.

Definition: ‘‘Y ou’’ shall mean the Plaintiff to whom these interrogatories are directed except that if

suit has been instituted by the representative of the estate of a decedent, ward, or incapable person,

‘‘you’’ shall also refer to the Plaintiff’s decedent, ward or incapable person unless the context of an

interrogatory clearly indicates otherwise.

In answering these interrogatories, the Plaintiff(s) is (are) required to provide all information within

their knowledge, possession or power. If an interrogatory has subparts, answer each subpart separately

and in full and do not limit the answer to the interrogatory as a whole. If any interrogatories cannot be

answered in full, answer to the extent possible.

(1) Please state your name, address and occupation.

(2) Please state the date and place of your marriage.

(3) Do you have any children? If so, state their names and dates of birth.

(4) Describe the nature of your loss of consortium claim.

(5) During your marriage, please list your employers, the length of time employed by each, and the

average number of hours worked per month.

(6) Prior to the incident which is the subject of this lawsuit (‘‘the incident’’), did your spouse regularly

perform work, services and/or chores (‘‘services’’) in or around the home?

(7) If the answer to the previous interrogatory is in the affirmative, please describe the nature and

frequency of such services.

(8) Subsequent to the incident, did such services change? If so, state how, and describe the impact

of this change on you.

(9) Subsequent to the incident, did anyone other than your spouse perform the services usually

performed by your spouse in and around the home?

(10) If the answer to the previous interrogatory is in the affirmative, please state the name(s) and

address(es) of each person(s), the amount paid, the period of time they were hired and what services

they performed.

(11) Have you or your spouse ever instituted legal proceedings seeking a divorce or separation? If

so, state when.

No. CV- : SUPERIOR COURT

(Plaintiff): JUDICIAL DISTRICT OF

VS. : AT

(Defendant): (Date)

(12) Did you, at any time during your marriage live apart from or separate yourself from your spouse?

If so, state when and for how long such separation occurred, and state the reason for such separation.

(13) Describe any change(s) in the affection your spouse expressed or displayed toward you following

the incident.

(14) If claimed, describe any change(s) in the frequency and satisfaction of your sexual relations

with your spouse following the incident.

(15) Describe any change(s) in the activities which you and your spouse enjoyed together before

the incident that you claim were caused by the incident.

(16) Within two years prior to the year of the incident up to the present, have you and/or your spouse

had any marriage counseling? If so, state the name of each person consulted and the dates consulted

or treated.

DEFENDANT,

BY___________________

I, _______________, hereby certify that I have reviewed the above interrogatories and responses

thereto and that they are true and accurate to the best of my knowledge and belief.

_____________________________

(Plaintiff)

Subscribed and sworn to before me this _____________ day of ___________, 20___.

_____________________________

Notary Public/

Commissioner of the Superior Court

CERTIFICATION

I certify that a copy of this document was or will immediately be mailed or delivered electronically or

non-electronically on (date)_________to all attorneys and self-represented parties of record and that

written consent for electronic delivery was received from all attorneys exempt from e-filing and self-represented parties of record who received or will immediately be receiving electronic delivery.

Name and address of each party and attorney that copy was or will immediately be mailed or

delivered to*

*If necessary, attach additional sheet or sheets with the name and address which the copy was or

will immediately be mailed or delivered to.

_________________________________________________________________________________

Signed (Signature of filer) Print or type name of person signing Date Signed

_________________________________________________________________________________

Mailing address (Number, street, town, state and zip code) or Email address, if applicable Telephone number

HISTORY—2026: In the first sentence of the certification, “exempt from e-filing” was added after “from all attorneys.”

COMMENTARY—2026: The changes to this form are consistent with the changes to the proof of service language in Section

10-14 (a).