Fill and Sign the Verified Statement of Fees Charged Colorado Form

 District Court  Denver Juvenile Court _________________________________County, Colorado Court 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 JDF 454 R1/18 VERIFIED STATEMENT OF FEES CHARGED