Fill and Sign the Petitioner 1 Full Name Form

JDF 503 R1-18 PETITION FOR CUSTODIAL ADOPTION Page 1 of 4District 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 PETITION FOR CUSTODIAL ADOPTION The Petitioner(s) being desirous of adopting a child so as to make said child for all intents and purposes the legal child of Petitioner(s) and to render him/her capable of inheriting their estate, state(s) the following facts:Information about the Petitioner(s):Petitioner #1: ____________________________________________________________________ (Full Name)Date of Birth: ________________ Race: ______________ Place of Birth: ____________________________Current Mailing Address: ___________________________________________________________________City & Zip: _______________________________________________________________________________Home Phone #: ____________________ Work Phone #: ___________________ Cell #: _________________Email:____________________________________ Length of Residence in Colorado:__________________ Occupation: ______________________________Place of residence at the time of birth of the child. _______________________________________________________________________________________Street Address CityStateZip Code Petitioner #2: ____________________________________________________________________ (Full Name)Date of Birth: ________________ Race: ______________ Place of Birth: ____________________________Current Mailing Address: ___________________________________________________________________City & Zip: _______________________________________________________________________________Home Phone #: ____________________ Work Phone #: ___________________ Cell #: _________________Email:____________________________________ Length of Residence in Colorado: __________________ Occupation: _____________________________Place of residence at the time of birth of the child. _______________________________________________________________________________________Street Address CityStateZip Code JDF 503 R1-18 PETITION FOR CUSTODIAL ADOPTION Page 2 of 4 If applicable, maiden name of adopting mother: _____________________ Date of Marriage: _____________Venue is proper in this matter because the Petitioner(s) reside(s) in this countyThe Petitioner(s) has/have consulted with the appropriate local County Department of Social Services concerning the possible eligibility of the Petitioner(s) and the child for temporary assistance for needy families (TANF), Medicaid, subsidized adoption and other services or public assistance administered by the County Department of Social Services on ___________________. The Petitioner(s) has/have attached as “Attachment A” a current fingerprint-based criminal history records check as required by §19-5-207(2.5)(a)(I)-(IV), C.R.S. The Petitioner(s) has/have attached as “Attachment B” the TRAILS background check as required by §19-5- 207, C.R.S. If the Petitioners has/have been convicted of a felony or misdemeanor in any of the following areas, please check the appropriate box and identify for the Court the date of the conviction and if it was a felony or misdemeanor. child abuse or neglect on ______________________ (date). Felony Misdemeanorspousal abuse on _______________________ (date).  Felony Misdemeanorany crime against a child on ____________________ (date). Felony Misdemeanor any crime, the underlying factual basis of which has been found by the Court to include an act of domestic violence on _______________________ (date). FelonyMisdemeanor violation of a Protection/Restraining Order on ____________________ (date). FelonyMisdemeanorany crime involving violence, rape, sexual assault, or homicide on _____________________ (date). FelonyMisdemeanor  any felony involving physical assault or battery on __________________________ (date). FelonyMisdemeanor any felony drug-related conviction within the past five years, at a minimum on _________________(date). FelonyMisdemeanorIdentify all children of the Petitioner(s) (both natural and adopted and both living and deceased). Full Name of ChildFull Name of Child Facts concerning the child to be adopted. (Do not fill in if placement is by an agency or Department of Social Services.Full Name: ___________________________________________ Date of Birth: _____________________Place of Birth: _______________________________ Relationship of child to Petitioner(s), if any ____________Place of Residence: _________________________________________________________________________The child is is not a member or eligible to be a member of an Indian tribe as defined by the Indian Welfare Act.If applicable, name of tribe _______________________________________________________________.Notice of this Petition has been provided to the parent or Indian custodian of the child and to the tribal agent of the tribe, as required by §19-1-126(1)(c), C.R.S. Reasonable efforts have been made to send notice to the identified persons as follows: ______________________________________________________________________________________________________________________________________________________________________________ JDF 503 R1-18 PETITION FOR CUSTODIAL ADOPTION Page 3 of 4Attach the postal receipts to this petition, indicating that notice was properly sent. If the postal receipts have not been returned at the time of filing, the postal receipts or copies shall be filed with the Court within ten days of the filing of this petition.If applicable, inquiries have been made by the County Department of Social Services or child placement agency to determine whether the child is an Indian child as follows: ______________________________________________________________________________________________________________________________________________________________________________The child has been in the care and custody of Petitioner(s) since _________________________________ (date).The legal custody of the child is with ______________________________________________________ (name).Full description of the property of the child, if any: ___________________________________________________________________________________________________________________________________________Name and address of the Guardian(s) of the child and estate of the child, if any, have been appointed: ____________________________________________________________________________________________________________________________________________________________________________________A certified copy of the Court orders granting legal guardianship or allocation of parental responsibilities (decision-making and parenting time) is attached hereto and incorporated herein by reference. Information about the Birth Parents of the Child:Full Name of Birth father: _______________________________________________________________________________________________________________________________________________________________Street Address City StateZip CodeFull Name of Birth Mother: ______________________________________________________________________________________________________________________________________________________________Street Address City StateZip CodeThe written consent(s) of the parent(s) is/are attached or is/are not attached.The child will not be the subject of a pending dependency and neglect action when the adoption is heard.If parental rights are relinquished, are terminated, or are being terminated in this action pursuant to §§19-5-101- 108, C.R.S., as amended, or parent is deceased, state details: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Wherefore, the Petitioner(s) pray(s) that a Decree of Adoption be entered herein declaring said child to be the child of Petitioner(s) and that the name of said child be changed to: ____________________________________________ (full name) and that said child shall be entitled to all of the rights and privileges and be subject to all of the obligations now conferred and imposed by law. JDF 503 R1-18 PETITION FOR CUSTODIAL ADOPTION Page 4 of 4 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 ___________________________________ Petitioner’s Attorney Signature, if any 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 Co-Petitioner) Signature of Co-Petitioner______________________________________Co-Petitioner’s Attorney Signature, if any