Fill and Sign the Affidavit Pursuant Form

 Municipal Court  County Court  District Court  Denver Juvenile  Denver Probate __________________________________ County, Colorado Court Address: Petitioner: ______________________________________ v. Respondent: _________________________________ COURT USE ONLY Attorney or Party Without Attorney (Name and Address): Phone Number: E-mail: FAX Number: Atty. Reg. #: Case Number: Division Courtroom AFFIDAVIT REGARDING CHILDREN PURSUANT TO §14-13-209, C.R.S. I _______________________________ (name of party) submit the following information to the Court: 1.  I request that I be permitted to omit the children’s address from this Affidavit because I fear that including the address will endanger the minor children. 2. The minor children are (list full name and date of birth): (Do not include address if number 1 above is checked.) Full Name of Child Date of Birth Current Address 3. The above-named children have lived with the following persons and in the following places within the last five years: (Give name and address of all persons the children have lived with within the last five years.) Name of Party Address (City/State/Zip Code) Time Period (Month/Year) Relationship to Child 4. A legal action for Dissolution of Marriage or Civil Union, Legal Separation, Paternity, or Allocation of Parental Responsibilities (Decision-Making and Parenting Time) with the above-named children identified in the action  has  has not been filed. If such an action has been filed, complete the information below: County Where Case Has Been Filed State Case Number Nature of Proceeding 5. I  have  have not participated as a party or witness or in any other capacity in any other court proceeding concerning custody of, or visitation, or parenting time with the above-named children in this or any other state. If so, please provide the following information. County Where Case Has Been Filed State Case Number Date of Hearing JDF 404 R2-18 AFFIDAVIT REGARDING CHILDREN PURSUANT TO §14-13-209, C.R.S. Page 1 of 2 6. I  do  do not know of any court proceedings that could affect this proceeding, including proceedings concerning enforcement of prior orders, domestic violence/abuse, protective/restraining orders, termination of parental rights, or adoption. If so, please provide the following information. County Where Case Has Been Filed State Case Number Nature of Proceeding 7. I  do  do not know of any person not a party to the proceeding who has physical custody or claims rights of parental responsibilities, legal custody, physical custody, visitation or parenting time with the above-named children. If yes, please provide the following information. Name of Person Address (Street, City, State, Zip Code) 8. I  do  do not understand that I have a continuing duty to inform the Court of any custody proceedings concerning the children in this or any other state when I obtain such information during this proceeding. 9. I  am  am not a Native American Indian and these children  are  are not subject to the provisions of the Indian Child Welfare Act.  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  Respondent) Signature of  Petitioner  Respondent JDF 404 R2-18 AFFIDAVIT REGARDING CHILDREN PURSUANT TO §14-13-209, C.R.S. Page 2 of 2