JDF 454 R 1 /1 8 VERIFIED STATEMENT OF FEES CHARGED District Court Denver Juvenile Court County, Colorado Court Address: IN THE MATTER OF THE PETITION OF: ( name of person(s) seeking to adopt) FOR THE ADOPTION OF A CHILD COURT U SE ONLY Attorney or Party Without Attorney (Name and Address): Phone Number: E - mail: FAX Number: Atty. Reg.#: Case Number: Division Courtroom VERIFIED STATEMENT OF FEES CHARGED The following fees have been charged to the Petitioner (s) relative to the adoption proceeding pursuant to 24719 - 5 - 208(4), C.R.S. and C.R.J.P. 6( b )(4): $ Filing fees: $ Publication fees: $ Personal service fees: $ Birth certificates: $ Hospital charges and medical fees: $ County department of social services fees: $ Child placement agency fees: $ Charges, gifts or charitable contributions: $ Other cons iderations or things of value: $ T otal Fees Charged : $ By checking this box, I am acknowledging I am filling in the blanks and not changing anything else on the form . By checking th is 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) (y ear) (city or other location, and state OR country (printed name of Petitioner) Signature of Petitioner Attorney Signature, if any American LegalNet, Inc. www.FormsWorkFlow.com