Fill and Sign the Affidavit and Advisement Concerning the Childs Potential Placement Colorado Form

DISTRICT COURT _________________COUNTY, COLORADO Juvenile Division Court Address: THE PEOPLE OF THE STATE OF COLORADO In the Interest of ________________________________ Minor Child(ren) And Concerning : ________________________________ Respondent . ▲ COURT USE ONLY ▲ Attorney or Party Without Attorney (Name and Address) Phone Number: Email: Fax Number: Atty Reg. #: Case Number : Division : Courtroom : RELATIVE AFFIDAVIT AND ADVISEMENT CONCERNING THE CHILD’S POTENTIAL PLACEMENT PURSUANT TO §19-3-403, C.R.S. PART I: ADVISEMENT TO EACH PARENT ATTENDING A TEMPORARY CUSTODY HEARING. This matter comes before the Court on ___________________________ (date). The Court hereby advises the parent(s) in this case of the following:  You are required to fill out the below placement information (Part II – Affidavit) fully and completely under penalties of perjury and contempt of court.  You are required to list the name, address and telephone number of every grandparent, aunt, uncle, brother, sister, half-sibling, and first cousin of the child(ren), other adults with a significant relationship to your child, and also include any comments concerning the appropriateness of such person as a potential placement for the child(ren).  If the child cannot be safely returned to the home of his or her parents, the Court will consider appropriate identified relatives who have a significant relationship with the child before making any decision regarding appropriate placement for the child.  If the child cannot be safely returned to the home of his or her parents, failure to identify the relatives in a timely manner may result in the child being placed permanently outside of the home.  The child may risk life-long damage to his or her emotional well-being if the child becomes attached to one caregiver and is later removed from the caregiver’s home.  The Court shall Order the County Department of Human Services to make reasonable efforts to contact appropriate and identified relatives within 30 days following the removal of the child and to inform them about placement possibilities. The attached placement information (Part II – Affidavit) must be returned to the Court (within 7 days after the Temporary Custody/Shelter hearing or at the next scheduled hearing, whichever occurs first by ______________ (date). I acknowledge that I have read and understand this advisement. ____________________________________________________ ____________________________________________________ Signature of Parent Printed Name ________________________________________ _______________________________________ Date Relationship to Child(ren) Page 1 of 5 JDF 559 R3-18 RELATIVE AFFIDAVIT AND ADVISEMENT CONCERNING THE CHILD’S POTENTIAL PLACEMENT This original signed Advisement shall be filed with the Court at the Temporary Custody/Shelter Hearing and a copy maintained by the Respondent(s) and their counsel. Case Name ___________________________ Case Number: ________________________ PART II: AFFIDAVIT By law, this form must be filed with the Court within seven (7) days after the Temporary Custody/Shelter Hearing or at the next scheduled hearing, whichever occurs first. Please fill out blanks below. Each Respondent shall complete a separate Affidavit . I, __________________________________________, a parent in this action, being duly sworn and upon oath, respond as follows to the requested information. 1. Family Member (The Child’s Grandmother) Maternal Paternal Full Name: ______________________________________ Relationship to Child: _________________ Home Address: _______________________________________________________________________ Home Telephone Number: ___________________________ Cell Number: ________________________ Email/Facebook/Twitter_________________________________________________________________ I want this person to be considered for placement of my child □ Yes □ No I want this person to be involved in Family Team Meetings □ Yes □ No I want this person to be involved in supporting my family, including Family Team Meetings □ Yes □ No Comments regarding the appropriateness of the child’s potential placement with this relative: _______________ _________________________________________________________________________________________ 2. Family Member (The Child’s Grandfather) Maternal Paternal Full Name: ______________________________________ Relationship to Child: ______________________ Home Address: ____________________________________________________________________________ Home Telephone Number: ___________________________ Cell Number: _____________________________ Email/Facebook/Twitter______________________________________________________________________ I want this person to be considered for placement of my child □ Yes □ No I want this person to be involved in Family Team Meetings □ Yes □ No Comments regarding the appropriateness of the child’s potential placement with this relative: _______________ _____________________________________________________________________________________ ____ 3. Family Member (The Child’s Aunt/Uncle) Maternal Paternal Full Name: ______________________________________ Relationship to Child: ______________________ Home Address:____________________________________________________________________________ Home Telephone Number: ___________________________ Cell Number: _____________________________ Email/Facebook/Twitter______________________________________________________________________ I want this person to be considered for placement of my child □ Yes □ No I want this person to be involved in Family Team Meetings □ Yes □ No Comments regarding the appropriateness of the child’s potential placement with this relative: _______________ _________________________________________________________________________________________ 4. Family Member (The Child’s Aunt/Uncle) Maternal Paternal Full Name: ______________________________________ Relationship to Child: ______________________ Page 2 of 5 JDF 559 R3-18 RELATIVE AFFIDAVIT AND ADVISEMENT CONCERNING THE CHILD’S POTENTIAL PLACEMENT Home Address: ____________________________________________________________________________ Home Telephone Number: ___________________________ Cell Number: _____________________________ Email/Facebook/Twitter______________________________________________________________________ I want this person to be considered for placement of my child □ Yes □ No I want this person to be involved in Family Team Meetings □ Yes □ No Comments regarding the appropriateness of the child’s potential placement with this relative: _______________ _________________________________________________________________________________________ 5. Family Member (The Child’s Sibling) Maternal Paternal Full Name: ______________________________________ Relationship to Child: ______________________ Home Address: ____________________________________________________________________________ Home Telephone Number: ___________________________ Cell Number: _____________________________ Email/Facebook/Twitter______________________________________________________________________ I want this person to be considered for placement of my child □ Yes □ No I want this person to be involved in Family Team Meetings □ Yes □ No Comments regarding the appropriateness of the child’s potential placement with this relative: _______________ _________________________________________________________________________________________ 6. Family Member (The Child’s Sibling) Maternal Paternal Full Name: ______________________________________ Relationship to Child: ______________________ Home Address: ____________________________________________________________________________ Home Telephone Number: ___________________________ Cell Number: _____________________________ Email/Facebook/Twitter______________________________________________________________________ I want this person to be considered for placement of my child □ Yes □ No I want this person to be involved in Family Team Meetings □ Yes □ No Comments regarding the appropriateness of the child’s potential placement with this relative: _______________ _________________________________________________________________________________________ 7. Family Member (The Child’s Half-Sibling) Maternal Paternal Full Name: ______________________________________ Relationship to Child: ______________________ Home Address:____________________________________________________________________________ Home Telephone Number: ___________________________ Cell Number: _____________________________ Email/Facebook/Twitter______________________________________________________________________ I want this person to be considered for placement of my child □ Yes □ No I want this person to be involved in Family Team Meetings □ Yes □ No Comments regarding the appropriateness of the child’s potential placement with this relative: _______________ _________________________________________________________________________________________ 8. Family Member (The Child’s Half-Sibling) Maternal Paternal Full Name: ______________________________________ Relationship to Child: ______________________ Home Address: ____________________________________________________________________________ Home Telephone Number: ___________________________ Cell Number: _____________________________ Email/Facebook/Twitter______________________________________________________________________ I want this person to be considered for placement of my child □ Yes □ No I want this person to be involved in Family Team Meetings □ Yes □ No Comments regarding the appropriateness of the child’s potential placement with this relative: _______________ _________________________________________________________________________________________ Page 3 of 5 JDF 559 R3-18 RELATIVE AFFIDAVIT AND ADVISEMENT CONCERNING THE CHILD’S POTENTIAL PLACEMENT 9. Family Member (The Child’s Cousin) Maternal Paternal Full Name: ______________________________________ Relationship to Child: ______________________ Home Address:____________________________________________________________________________ Home Telephone Number: ___________________________ Cell Number: _____________________________ Email/Facebook/Twitter______________________________________________________________________ I want this person to be considered for placement of my child □ Yes □ No I want this person to be involved in Family Team Meetings □ Yes □ No Comments regarding the appropriateness of the child’s potential placement with this relative: _______________ _________________________________________________________________________________________ 10. Family Member (The Child’s Cousin) Maternal Paternal Full Name: ______________________________________ Relationship to Child: ______________________ Home Address: ____________________________________________________________________________ Home Telephone Number: ___________________________ Cell Number: _____________________________ Email/Facebook/Twitter______________________________________________________________________ I want this person to be considered for placement of my child □ Yes □ No I want this person to be involved in Family Team Meetings □ Yes □ No Comments regarding the appropriateness of the child’s potential placement with this relative: _______________ _________________________________________________________________________________________ 11. Family Member (The Child’s Great-Grandmother) Maternal Paternal Full Name: ______________________________________ Relationship to Child: ______________________ Home Address: ____________________________________________________________________________ Home Telephone Number: ___________________________ Cell Number: _____________________________ Email/Facebook/Twitter______________________________________________________________________ I want this person to be considered for placement of my child □ Yes □ No I want this person to be involved in Family Team Meetings □ Yes □ No Comments regarding the appropriateness of the child’s potential placement with this relative: _______________ _________________________________________________________________________________________ 12. Family Member (The Child’s Great-Grandfather) Maternal Paternal Full Name: ______________________________________ Relationship to Child: ______________________ Home Address: ____________________________________________________________________________ Home Telephone Number: ___________________________ Cell Number: _____________________________ Email/Facebook/Twitter______________________________________________________________________ I want this person to be considered for placement of my child □ Yes □ No I want this person to be involved in Family Team Meetings □ Yes □ No Comments regarding the appropriateness of the child’s potential placement with this relative: _______________ _________________________________________________________________________________________ 13 . Please list any other adults who could supervise visitation, provide transportation, babysit, or call in an emergency. _________________________________________________________________________________________ _________________________________________________________________________________________ Home Address: ___________________________________________________________________________ Home Telephone Number: ________________________Cell Number: ________________________________ Page 4 of 5 JDF 559 R3-18 RELATIVE AFFIDAVIT AND ADVISEMENT CONCERNING THE CHILD’S POTENTIAL PLACEMENT Email/Facebook/Twitter______________________________________________________________________ Please list any other adults (example: teachers, coach, neighbor, etc.) and their phone numbers, who my child has a relationship with, and I want them to be considered for placement of my child: _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________  By checking this box, I am acknowledging I am filling in the blanks and not changing anything else on the form.  By checking this box, I am acknowledging that I have made a change to the original content of this form. VERIFICATION I declare under penalty of perjury under the law of Colorado that the foregoing is true and correct. Executed on the ______ day of ________________, _______, at ______________________________________ (date) (month) (year) (city or other location, and state OR country ______________________________________ ______________________________________ (Printed name of Petitioner/Plaintiff ) Signature of Petitioner/Plaintiff ______________________________________ Relationship to Child(ren) _____________________________________________________________________________________ The Court, County Department of Human Services, each parent, the Guardian Ad Litem, and Counsel for each parent shall receive a copy of this form. Page 5 of 5 JDF 559 R3-18 RELATIVE AFFIDAVIT AND ADVISEMENT CONCERNING THE CHILD’S POTENTIAL PLACEMENT