Fill and Sign the I Certify that I Am the Birth Father Mother of Name of Form

JDF 509 R1/18 CONSENT TO ADOPTION – CUSTODIAL PARENTDistrict Court Denver Juvenile Court__________________________________County, ColoradoCourt Address:IN THE MATTER OF THE PETITION OF:______________________________ (name of person(s) seeking to adopt)FOR THE ADOPTION OF A CHILD COURT USE ONLY Attorney or Party Without Attorney (Name and Address): Phone Number: E-mail:FAX Number: Atty. Reg. #:Case Number:Division Courtroom CONSENT TO ADOPTION – CUSTODIAL PARENT 1.I certify that I am the birth father mother of ________________________________ (name of child) and I certify that the Respondent is the birth father mother of said child.2. I certify that I am consenting to the adoption of the child by the above-named Petitioner(s). 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/Mother Signature of F ather/Mother