Fill and Sign the Colorado Rights 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 - MOTHER NAME OF CHILD____________________________________________________________ (DOB) ____________________ 1. What is your name? ________________________________________________________________________________ 2. What is your address? ______________________________________________________________________________ 3. What is your date of birth? ___________________________________________________________________________ 4. Are you the birth mother of the child who is subject to this action? ____________________________________________ 5. What is the name of the birth father of the child? __________________________________________________________ 6. What is his address? _______________________________________________________________________________ 7. What is his age and date of birth? _____________________________________________________________________ 8. Were you married at the time of the conception or at the time of the birth of the child? _____________________________ 9. Have you ever been married, or held yourself out to be married? _____________________________________________ 10. Have you ever been divorced? ______________ Date and place of divorce: ___________________________________ Name of Husband __________________________________________________________________________________ 11. Were you living with any man at the time of the conception or at the time of the birth of the child? ___________________ If so, what is his name, address, age and date of birth (if different than questions 5, 6 & 7)? ________________________ _________________________________________________________________________________________________ 12. Are you now living with any man, or have you lived with any man since the birth of the child? _______________________ If so, what is his name, address, age and date of birth (if different than questions 5, 6 & 7)? _______________________ _________________________________________________________________________________________________ 13. Have you received support payments or promises of support with respect to the child from anyone? _________________ If so, what is the name, address, age and date of birth (if different than questions 5, 6 & 7)? ________________________ _________________________________________________________________________________________________ 14. Have you received any support or promises of support from any man in connection with your pregnancy? _____________ If so, what is his name, address, age & date of birth (if different than questions 5, 6 & 7)? __________________________ _________________________________________________________________________________________________ 15. Has any man paid any of your medical expenses in connection with your pregnancy or the birth of the child? __________ If so, what is his name, address, age and date of birth (if different than questions 5, 6 & 7)? ________________________ _________________________________________________________________________________________________ JDF 513 4/00 RELINQUISHMENT INTERROGATORY – MOTHER 1 16. Has any man in any way indicated, acknowledged or declared that he is, or may be, the father of this child? ___________ If so how was this indicated? _________________________________________________________________________ What is his name, address, age and date of birth (if different than questions 5, 6 & 7)? ____________________________ _________________________________________________________________________________________________ 17. Is there any possibility that anyone else could be the birth father of this child? ___________________________________ If so, what is his name, address, age and date of birth (if different from questions 5, 6 & 7)? ________________________ _________________________________________________________________________________________________ 18. Are you or the birth father a member of an Indian tribe? ________________ Are you or the child eligible for membership? ______________ If so, state name of member (or eligible for membership) and name and address of Indian tribe with which you or the child are affiliated: ____________________________________________________________________ _________________________________________________________________________________________________ Birth mother’s maiden name (if applicable): ______________________________________________________________ 19. Whose name is listed on the child’s birth certificate as the birth father of the child? _______________________________ What is his address, age and date of birth (if different than questions 5, 6 & 7)? _________________________________ _________________________________________________________________________________________________ 20. Do you understand that if you wanted to keep the child the birth father of the child would be obligated to support the child, and if he failed to do so, you could file a civil action to obtain support money for the child; and if he found to be the birth father, he could be ordered to pay support for the child? ____________________________________________________ 21. 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? _______________________________________________________________________ 22. Knowing these alternatives are available to you, do you still feel that it is best to relinquish the child? _________________ 23. Do you know that you will never be able to change your mind about this matter after the Final Order of Relinquishment is entered? _________________________________________________________________________________________ 24. Do you understand that you may not know in what home the child has been placed? _____________________________ 25. Do you understand all of your legal rights with respect to this child? ___________________________________________ Do you want any further explanation of those rights? _______________________________________________________ 26. Do you relinquish all of your legal rights, obligations, and claims to the child? ___________________________________ 27. Do you believe that relinquishment is in the best interest of the child? _________________________________________ 28. What are some of the reasons for your belief that this relinquishment is in the best interest of the child? ______________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 29. Do you understand that you have the right to be represented by a lawyer in these proceedings? ____________________ 30. Do you want to be represented by an attorney? ___________________________________________________________ 31. Have you been thoroughly counseled in this matter? _______________________________________________________ 32. By whom were you counseled and approximately what amount of time have you spent in such counseling? ___________ _________________________________________________________________________________________________ 33. Are you satisfied with the counseling, which you have received? _____________________________________________ 34. Has there been any coercion, pressure or undue influence placed on you by anyone to force you to arrive at the decision to relinquish? _____________________________________________________________________________________ 35. Has anyone promised you anything or given you anything, including paying any costs on your behalf, in order to get you to relinquish? _____________________________________________________________________________________ JDF 513 4/00 RELINQUISHMENT INTERROGATORY – MOTHER 2 36. Are you making this decision voluntarily of your own free will? _______________________________________________ 37. Do you want to have more time in which to consider this matter further? _______________________________________ 38. If the birth father’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 his rights are terminated, even though the delay would not be a basis for you to change your mind regarding relinquishment in the future? _________________________________________________________ ___________________________________________ Petitioner STATE OF COLORADO COUNTY OF ______________________________ __________________________________________________ being first duly sworn, upon oath deposes and states that she has read the foregoing questions and that the answers, written in her own handwriting, are true of her own knowledge except for those of which she has no knowledge, and as to them she believes them to be true. ___________________________________________ Petitioner Subscribed and sworn to before me this ___________ day of _________________________________________, _________. My commission expires: ______________________ ___________________________________________ Deputy Clerk/Notary Public JDF 513 4/00 RELINQUISHMENT INTERROGATORY – MOTHER 3