JDF 512 R 3 /1 8 RELINQUISHMENT INTERROGATORY FATHER Page 1 of 3 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 RELINQUISHMENT INTERROGATORY - FATHER N ame of Child: D ate of Birth: 1. What is your name? 2. What is your address? 3. What is your date of birth? 4. Are you the alleged, presumed, or birth father of the child who is subject of this action ? Yes No 5. What is the name of the birth mother of the child? 6. What is her address? 7. What is her age and date of birth? 8. Were you married to the birth mother of the child at the time of conception? Yes No 9. Were you married to the birth mother of the child at the time of the birth c hi ld? Yes No 10. Have you ever been married, or held yourself out to be married to the birth mother? Yes No If Yes , have you been divorced? Yes No If Yes , identify d ate and place of divorce: 11. Were you living w it h the birth mother (a) at the time of the conception or (b) at the time of the birth of the child? If so, at what address? American LegalNet, Inc. www.FormsWorkFlow.com JDF 512 R 3 /1 8 RELINQUISHMENT INTERROGATORY FATHER Page 2 of 3 12. Are you now living with the birth mother, or have you lived with the birth mother since the birth of the child? Yes No If so, at what address? 13. Have you paid support payments or made promises of support to the birth mother with respect to the child? Yes No 14. Have you paid any of expenses in connection with the pregnancy or birth of the child? Yes No 15. Are you a memb er of an Indian tribe? Yes No Are you or the child eligible for membership? Yes No If Yes , identify the name of member (or eligible for membership) and name and address of Indian tribe with which you or the child are affiliated: 16. Do you understand that if you wanted to keep the child, the birth mother of the child would be obligated to support the chi ld and, if she failed to do so, you could file a civil action to obtain support money for the child and she could be ordered to pay support for the child? Yes No 17. Do you understand that if you needed fi nancial aid to care for the child you may apply for public assistance through the Department of Social Services? Yes No 18. Knowing these alternatives are available to you, do you still feel that it is best to relinquish the child? Yes No 19. Do you know that you will never be able to change your mind about this matter after the Final Order of Relinquishment is entered? Yes No 20. Do you understand that you may not know in what home the child has been placed? Yes No 21. Do you understand all of your legal rights with respect to this child? Yes No Do you want any further explanation of those rights? Yes No 22. Do you relinquish all of your legal rights, obligations, and claims to the child? Yes No 23. Do you believe that relinquishment is in the best interest of the child? Yes No 24. What are some of the reasons for your belief that this relinquishment is in the best interest of the child? American LegalNet, Inc. www.FormsWorkFlow.com JDF 512 R 3 /1 8 RELINQUISHMENT INTERROGATORY FATHER Page 3 of 3 25. Do you understand that you have the right to be represented by a lawyer in these proceedings? Yes No 26. Do you want to be represented by an attorney? Yes No 27. Have you been thoroughly counseled in this matter? Yes No 28. By whom were you counseled and approximately what amount of time have you spent in such counseling? 29. Are you satisfied with the counseling which you have received? Yes No 30. Has there been any coercion, pressure or undue influence placed on you by anyone to force you to arrive at the decision to relinquish? Yes No 31. Has anyone promised you anything or given you anything, including paying any costs on your behalf, in order to get you to relinquish? Yes No 32. Are you making this decision voluntarily of your own free will? Yes No 33. Do you want to have more time in w hich to consider this matter further? Yes No 34. entry of your final relinquishment order until her rights are terminated, even though the delay would not be a basis for you to change your min d regarding relinquishment in the future? Yes No 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 cont ent 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 (printe d name of Father) Signature of Father American LegalNet, Inc. www.FormsWorkFlow.com