JDF 453 R 3 / 1 8 AFFIDAVIT OF RELINQUISHMENT COUNSELING Page 1 of 2 District Court Denver Juvenile Court County, Colorado Court Address: I n the Matter of the Petition of : And Petitioner(s) F or the Relinquishment 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 AFFIDAVIT OF RELINQUISHMENT COUNSELING I, of County Department of Social Services/Child Placement Agency, state that I provided counseling to on the following dates concerning the . 1. The nature and extent of counseling included the following: Information to Petitioner concerning the permanence of the decision to relinquish and the impact of the decision on Petitioner now and in the future. parents. If Petitioner was pregnant , the Petitioner was refer red for medical care and a determination of eligibility for medical assistance. Information about alternatives to relinquishment and a referral to private and public resources that may meet Information about relinquishment services necessary to protect the interests and welfare of the child if the child was born in a state institution. Information that if Petitioner applies for public assistance for Petitioner or the child, Petitioner must cooperate with the Child Support Enforceme nt Unit for the establishment of a child support order. That all information, except non - identifying information as defined in 24719 - 1 - 103(80), C.R.S., obtained in the course of relinquishment counseling, is confidential, unless the parent provides written information or a court orders a release of information. Other counseling provided: American LegalNet, Inc. www.FormsWorkFlow.com JDF 453 R 3 / 1 8 AFFIDAVIT OF RELINQUISHMENT COUNSELING Page 2 of 2 2. detail. 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 Counselor) Signature of Counselor American LegalNet, Inc. www.FormsWorkFlow.com