JDF 53 4 8 - 17 REQUEST FOR ACCESS TO JUVENILE PERSONAL RECORDS Page 1 of 3 District Court Juvenile Court County, Colorado Court Address: In the Matter of the Adoption of: Birth Name of Former Ward of State (If known) Current Legal Name o f Former Ward of State COURT USE ONLY Attorney or Party Without Attorney (Name and Address): Phone Number: E - mail: FAX Number: Atty. Reg. #: Case Number: Division Courtroom REQUEST FOR ACCESS TO JUVENILE PERSONAL RECORDS I, , (name) request access to all personal records as defined by section 19 - 5 - 305.5 ( 1 ) ( c ) (I),C.R.S., in the court possession, that may include : the former ward original and /or amended birth certificate, the Final Decree of Adoption, the Final Order of Relinquishment , the Order of Termination of P arental Rights , the temporary waiver of custody , the name of the former ward before placement in adoption, if adopted, the name and address of each birth parent as they appear in the birth records or other documents, including other information that might personally identify a birth parent , the name and address of each adoptive parent, if adopted, a physical description of the birth parents, the educational backgro und of the birth parents, the occupation of the birth parents, genetic information about the birth family, social information about the birth parents whether the former ward has siblings or half - siblings, and, if so, the names and addresses of the siblings and half - siblings, and the placement history of the former ward . 1. Information about the person making the request (Requestor) : Name: Date of Birth : Relationship to Former Ward : Stre et Address : Mailing Address, if different: City: State: Zip Code: Daytime Phone #: Email Address: Evening Phone #: 2. Information regarding the Adoption , if the former ward was adopted : Name of Adoptive Pare nt(s): Date of Adoption (on or about): County of Adoption: American LegalNet, Inc. www.FormsWorkFlow.com JDF 53 4 8 - 17 REQUEST FOR ACCESS TO JUVENILE PERSONAL RECORDS Page 2 of 3 3. I am an eligible party allowed to have access to the personal records in this case because I am: a. The former ward b. A spouse or partner in a civil union of a former ward c. An adult descendant of the former ward d. An adult sibling or half - sibling of the former ward e. A legal representative of one of the above listed individuals AND I have notari zed written consent from the former ward or proof that the former ward is deceased NOTE: You will be required to provide proof of your identity and establish your relationship to the former ward to receive personal records pursuant to section s 19 - 5 - 305. 5(2), (3) C.R.S. Ask the court for more details or click here for a list of acceptable forms of identification and documents to establish how you are related to the former ward . If you are submitting your request by mail, please send copies of these documents to the court for review (do not send originals). The court will destroy the copies after the information has been reviewe d. If you send originals, y ou will be responsible for the cost of returning the originals to you by certified mail , restricted delivery to ensure that the documents are delivered only to you . 4. I am not one of the individuals listed above in number 3 or do not have the required proof , however, good cause exists to allow me to have access to the personal records pursuant to section 19 - 1 - 309, C.R.S. (explain below). Note: If you checked this box , file the Order ( J DF 535 ) with the Court. 5. The provisions of the Indian Child Welfare Act apply to the former ward as follows: 6. When the court locates the personal records that I am requesting, I request: T hat the court mail the records to me by certified mail restricted delivery (you will be responsible for the cost of mailing); OR American LegalNet, Inc. www.FormsWorkFlow.com JDF 53 4 8 - 17 REQUEST FOR ACCESS TO JUVENILE PERSONAL RECORDS Page 3 of 3 T hat the court notify me when the records are avai lable , and I will come to the court in person to inspect and/or copy the records (you will be responsible for any copying costs). VERIFICATION AND ACKNOWLEDGEMENT I swear/affirm under oath that I have read the foregoing Requ est and that the statements set forth therein are true an d correct. ( P rinted name of Requestor ) Signature of Requestor Date NOTE: If you are submitting your request by mail, you must sign this form in front of a Notary Public. If you are submitting your request in person, you do not need to sign this form in front of a Notary Public. The foregoing Request for Access to Juvenile Pe rsonal Records was acknowledged before me in the County of , State of , this day of , 20, by the Requestor . My Commission Exp ires: Notary Public FOR CLERK USE ONLY BELOW THIS LINE (check the boxes below) The requesting party has presented: Identification provided: AND D ocumentation establishing his/her relationship to the former ward provided: If the request was received by mail: Copies of the documents described above received from the Requestor proving identity and establishing his/her relationship to the former ward were reviewed and destroyed on (date). If originals of the d ocuments described above were received from Requestor , the originals were returned to the Requestor by certified mail restricted delivery on(date). The certified mail receipt was received by the court on (date). Tracking numb er: . NOTE: After the receipt is received and the tracking number is noted on the form, destroy the receipt. Clerk Signature Date American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com