JDF 513 R 3 /1 8 RELINQUISHMENT INTERROGATORY MOTHER Page 1 of 4 District Court Denver Juvenile Court County, Colorado Court Address: In 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 - MOTHER 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 birth mother of the child who is subject to this action? Yes No 5. What is the name of the birth father of the child? 6. What is his address? 7. What is his age and date of birth? 8. Were you married at the time of the conception or at the time of the birth of the child? Yes No 9. Have you ever been married, or held yourself out to be married? Yes No 10. Have you ever been divorced? Yes No If Yes , identify date and place of divorce: Name of Husband: American LegalNet, Inc. www.FormsWorkFlow.com JDF 513 R 3 /1 8 RELINQUISHMENT INTERROGATORY MOTHER Page 2 of 4 11. Were you living with any man at the time of the conception or at the time of the birth of the child? Yes No If Yes , identify his name, address, age and date of birth (if different than questions 5, 6 & 7) . 12. Are you now living with any man, or have you lived with any man since the birth of the child? Yes No If Yes , identify his name, address, age and date of birth (if different than questions 5, 6 & 7) . 13. Have you received support payments or promises of support with respect to the child from anyone? Yes No If Yes , identify the name, addres s, age and date of birth (if different than questions 5, 6 & 7) . 14. Have you received any support or promises of support from any man in connection with your pregnancy? Yes No If Yes , identify his name, address, age & date of birth (if different than questions 5, 6 & 7) . 15. Has any man paid any of your medical expenses in connection with your pregnancy or the birth of the child? Yes No If Yes, identify his name, address, age & date of birth (if different than questions 5, 6 & 7) . 16. Has any man in any way indicated, acknowledged or declared that he is, or may be, the father of this child? Yes No If Yes , how was this indi cated? Identify his name, address, age and date of birth (if different than questions 5, 6 & 7) . 17. Is there any possibility that anyone else could be the birth father of this child? Yes No If Yes identify his name, address, age and date of birth (if different from questions 5, 6 & 7) . American LegalNet, Inc. www.FormsWorkFlow.com JDF 513 R 3 /1 8 RELINQUISHMENT INTERROGATORY MOTHER Page 3 of 4 18. Are you or the birth father a member of an Indian tribe? Yes No Are you or the child eligible for membership? Yes No If Yes , state name of member (or eligible for membership) and name and address of Indian tribe with which you or the child are affiliated: Bi 19. as the birth father of the child? What is his address, age and date of birth (if different than questions 5, 6 & 7)? 20. Do you understand that if you wanted to keep the child the birth father of the child would be ob ligated to support the child, and if he failed to do so, you could file a civil action to obtain support money for the child; and if he found to be the birth father, he could be ordered to pay support for the child? Yes No 21. Do you understand that if you needed financial aid to care for the child you may apply for public assistance through the Department of Social Services? Yes No 22. Knowing these alternatives are available to you, do you still feel that it is best to relinquish the child? Yes No 23. 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 24. Do you understand that you may not know in what home the child has been placed? Yes No 25. 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 26. Do you relinquish all of your legal rights, obligations, and claims to the child? Yes No 27. Do you believe that relinquishment is in the best interest of the child? Yes No 28. What are some of the reasons for your belief that this relinquishment is in t he best interest of the child? American LegalNet, Inc. www.FormsWorkFlow.com JDF 513 R 3 /1 8 RELINQUISHMENT INTERROGATORY MOTHER Page 4 of 4 29. Do you understand that you have the right to be represented by a lawyer in these proceedings? Yes No 30. Do you want to be represented by an attorney? Yes No 31. Have you been thoroughly counseled in this matter? Yes No 32. By whom were you counseled and approximately what amount of time have you spent in such counseling? 33. Are you satisfied with the counseling, which you have received? Yes No 34. 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 35. 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 36. Are you making this decision voluntarily of your own free will? Yes No 37. Do you want to have more time in which to consider this matter further? Yes No 38. entry of your final relinquishment order until his 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 conte nt 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 Mother) Signature of Mother American LegalNet, Inc. www.FormsWorkFlow.com