JDF 503 R 1 - 1 8 PETITION FOR CUSTODIAL ADOPTION Page 1 of 4 District Court Denver Juvenile Court C ounty, 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 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 #: E mail: Length of Residence in Colorado: Occupation: Place of residence at the time of birth of the child. Street Address City State Zip 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 c hild. Street Address City State Zip Code American LegalNet, Inc. www.FormsWorkFlow.com JDF 503 R 1 - 1 8 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 county The 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 tempor ary 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 Attachment a curren t fingerprint - based criminal history record s check as required by 24719 - 5 - 207(2.5 ) (a)(I) - (IV), C.R.S. The Petitioner (s) has /have Attachment - 5 - 207, C.R.S. If the Petitioners has/have been convi cted 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 Misdemeanor spousal abuse on (date). Felony Misdemeanor any 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 ac t of domestic violence on (date). Felony Misdemeanor violation of a Protection/Restraining Order on (date). Felony Misdemeanor any crime involving violence, rape, sexual assault, or homicide on (date). Felony Misdemeanor any felony involving physical assault or battery on (date). Felony Misdemeanor any felony drug - related convi ction within the past five years, at a minimum on (date). Felony Misdemeanor Identify all children of the Petitioner(s) (both natural and adopted and both living and deceased). Full Name of Child Full 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 24719 - 1 - 126(1)(c), C.R.S. Reasonable efforts have been made to send notice to the identified persons as follows: American LegalNet, Inc. www.FormsWorkFlow.com JDF 503 R 1 - 1 8 PETITION FOR CUSTODIAL ADOPTION Page 3 of 4 Attach 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: S treet Address City State Zip Code Full Name of Birth Mother: Street Address City State Zip Code The written consent(s) of the parent(s) is/are attached o r 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 24724719 - 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. American LegalNet, Inc. www.FormsWorkFlow.com JDF 503 R 1 - 1 8 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 e lse 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 ( P rinted name of Petitioner) Signature of Petitioner ture, 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 ( P rinte d name of Co - Petitioner) Signature of Co - Petitioner Co - American LegalNet, Inc. www.FormsWorkFlow.com