Fill and Sign the Colorado Name Time Form

 District Court  Denver Juvenile Court _________________________________________ County, Colorado Court Address: IN THE MATTER OF THE ADOPTION OF : Birth Name of Adoptee (If known) A ND CONCERNING Current Legal Name of Petitioner COURT USE ONLY Attorney or Party Without Attorney (Name and Address): Phone Number: E-mail: FAX Number: Atty. Reg.#: Case Number: Division Courtroom AFFIDAVIT OF A BIRTH MOTHER WHO USED A FICTITIOUS NAME AT THE TIME OF RELINQUISHMENT OF A CHILD I, _______________________________________________________________________________, declare under oath that: My current address is: __________________________________________________________________________________. (Street Address, City, State, Zip) My date of birth is: ________________________________ My current telephone numbers are: (Home) ________________________________ (Work) ___________________________ At the time of the relinquishment of my child, I used the alias: My legal name at the time of the relinquishment was: My maiden name was: ______ At relinquishment my child’s name was: _____  Fictitious  Non-Fictitious surname. If known, what was the name of the agency awarded custody of the child? ________________________________________ If known, adoption agency handling relinquishment/termination: _________________________________________________ At relinquishment my age was: ___________ My occupation was: _______________________________________________ If a student, what year of high school/college? My city and state of residence was: My height was: My weight was: My parents  were aware  were unaware of my pregnancy. Name of my mother: __ Name of my father: ______ Were there any health problems  of self  of parents? Specify: _______________________________________ I  was  was not married to the father of my child I  was  was not married. If married, name of spouse: I  was  was not in a maternity home. Name of home: Address of home: What was the name of the birth father listed in the relinquishment? His age was: ___ His occupation was: ______________ JDF 344A R2-18 AFFIDAVIT OF A BIRTH MOTHER WHO USED A FICTITIOUS NAME Page 1 of 2 AT THE TIME OF RELINQUISHMENT OF A CHILD If a student, what year of high school/college? His city and state of residence was: His height was: His weight was: Did  he  his parents have any health problems? Specify: A copy of my birth certificate is submitted with this Affidavit.  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) Signature of Petitioner JDF 344A R2-18 AFFIDAVIT OF A BIRTH MOTHER WHO USED A FICTITIOUS NAME Page 2 of 2 AT THE TIME OF RELINQUISHMENT OF A CHILD