Fill and Sign the Court Adoption and Permanency Resource Guide California Form

JDF 344A R2-18 AFFIDAVIT OF A BIRTH MOTHER WHO USED A FICTITIOUS NAME Page 1 of 2AT THE TIME OF RELINQUISHMENT OF A CHILD  District Court  Denver Juvenile Court_________________________________________ County, ColoradoCourt Address:IN THE MATTER OF THE ADOPTION OF:Birth Name of Adoptee (If known) AND CONCERNINGCurrent 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 2 of 2AT 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