Fill and Sign the People V Juvenile Court 1995 Colorado Supreme Court Form

JDF 454 R1/18 VERIFIED STATEMENT OF FEES CHARGED District 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 VERIFIED STATEMENT OF FEES CHARGED The following fees have been charged to the Petitioner(s) relative to the adoption proceeding pursuant to §19-5- 208(4), C.R.S. and C.R.J.P. 6(b)(4): Attorney’s fees: $ _______________________________Filing fees: $ _______________________________Publication fees: $ _______________________________Personal service fees: $ _______________________________Birth certificates: $ _______________________________Hospital charges and medical fees: $ _______________________________County department of social services fees: $ _______________________________Child placement agency fees: $ _______________________________Charges, gifts or charitable contributions: $ _______________________________Other considerations or things of value: $ _______________________________Total Fees Charged: $ _______________________________  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 ___________________________________Attorney Signature, if any