Fill and Sign the Colorado Relinquishment Form

 District Court  Denver Juvenile Court ____________________County, Colorado Court Address: In the Matter of the Petition of: ______________________________________________________ And _______________________________________________Petitioner(s) For the Relinquishment of a Child, ___________________________________________________________ (child’s name) COURT USE ONLY Attorney or Party Without Attorney (Name and Address): Phone Number: E-mail: FAX Number: Atty. Reg.#: Case Number: Division Courtroom RELINQUISHMENT INTERROGATORY - FATHER Name of Child: _____________________________________________ Date of Birth: ____________________ 1. What is your name? _____________________________________________________________________ 2. What is your address? ____________________________________________________________________ 3. What is your date of birth? _________________________________________________________________ 4. Are you the alleged, presumed, or birth father of the child who is subject of this action?  Yes  No 5. What is the name of the birth mother of the child? _______________________________________________ 6. What is her address? _____________________________________________________________________ 7. What is her age and date of birth? ___________________________________________________________ 8. Were you married to the birth mother of the child at the time of conception?  Yes  No 9. Were you married to the birth mother of the child at the time of the birth c hild?  Yes  No 10. Have you ever been married, or held yourself out to be married to the birth mother?  Yes  No If Yes , have you been divorced?  Yes  No If Yes , identify date and place of divorce: ______________________________________________________ 11. Were you living with the birth mother (a) at the time of the conception or (b) at the time of the birth of the child? __________________________ If so, at what address? ____________________________________________________________________ 12. Are you now living with the birth mother, or have you lived with the birth mother since the birth of the child?  Yes  No JDF 512 R3/18 RELINQUISHMENT INTERROGATORY – FATHER Page 1 of 3 If so, at what address? ____________________________________________________________________ 13. Have you paid support payments or made promises of support to the birth mother with respect to the child?  Yes  No 14. Have you paid any of the biological mother’s expenses in connection with the pregnancy or birth of the child?  Yes  No 15. Are you a member of an Indian tribe?  Yes  No Are you or the child eligible for membership?  Yes  No If Yes , identify the name of member (or eligible for membership) and name and address of Indian tribe with which you or the child are affiliated: ______________________________________________________ 16. Do you understand that if you wanted to keep the child, the birth mother of the child would be obligated to support the child and, if she failed to do so, you could file a civil action to obtain support money for the child and she could be ordered to pay support for the child?  Yes  No 17. Do you understand that if you needed financial aid to care for the child you may apply for public assistance through the Department of Social Services?  Yes  No 18. Knowing these alternatives are available to you, do you still feel that it is best to relinquish the child?  Yes  No 19. Do you know that you will never be able to change your mind about this matter after the Final Order of Relinquishment is entered?  Yes  No 20. Do you understand that you may not know in what home the child has been placed?  Yes  No 21. Do you understand all of your legal rights with respect to this child?  Yes  No Do you want any further explanation of those rights?  Yes  No 22. Do you relinquish all of your legal rights, obligations, and claims to the child?  Yes  No 23. Do you believe that relinquishment is in the best interest of the child?  Yes  No 24. What are some of the reasons for your belief that this relinquishment is in the best interest of the child? 25. Do you understand that you have the right to be represented by a lawyer in these proceedings?  Yes  No 26. Do you want to be represented by an attorney?  Yes  No JDF 512 R3/18 RELINQUISHMENT INTERROGATORY – FATHER Page 2 of 3 27. Have you been thoroughly counseled in this matter?  Yes  No 28. By whom were you counseled and approximately what amount of time have you spent in such counseling? _______________________________________________________________________________________ 29. Are you satisfied with the counseling which you have received?  Yes  No 30. Has there been any coercion, pressure or undue influence placed on you by anyone to force you to arrive at the decision to relinquish?  Yes  No 31. Has anyone promised you anything or given you anything, including paying any costs on your behalf, in order to get you to relinquish?  Yes  No 32. Are you making this decision voluntarily of your own free will?  Yes  No 33. Do you want to have more time in which to consider this matter further?  Yes  No 34. If the birth mother’s rights cannot be terminated at the time of your hearing, are you requesting a delay in the entry of your final relinquishment order until her rights are terminated, even though the delay would not be a basis for you to change your mind regarding relinquishment in the future?  Yes  No  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 Father) Signature of Father JDF 512 R3/18 RELINQUISHMENT INTERROGATORY – FATHER Page 3 of 3