JDF 344A R 2 - 1 8 AFFIDAVIT OF A BIRTH MOTHER WHO USED A FICTITIOUS NAME Page 1 of 2 AT THE TIME OF RELINQUISHMENT OF A CHILD District Court Denver Juvenile Court County, Colorado Court Address: IN THE MATTER OF THE ADOPTION OF : Birth Name of Adoptee (If known) A ND CONCERNING Current Legal Name of Petitioner COURT USE ONLY Attorney or Party Without Attorney (Name and Address): Phone Number: E - mail: FAX Number: Atty. Reg.#: Case Number: Division Courtroom AFFIDAVIT OF A BIRTH MOTHER WHO USED A FICTITIOUS NAME AT THE TIME OF RELINQUISHMENT OF A CHILD I, , de clare under oath that: My current address is: . (Street Address, City, State, Zip) My date of birth is: My current telephone numbers ar e: (Home) (Work) At the time of the relinquishment of my child, I used the alias: My legal name at the time of the relinquishment was: My maiden name was: At relin Fictitious Non - Fictitious surname. If known, what was the name of the agency awarded custody of the child? If known, adoption agency handling relinquishment/termination: At relinquishment my age was: My occupation was: If a student, what year of high school/college? My city and state of residence was: My height was: My weight was: My parents were aware were unaware of my pregnancy. Name of my mother: Name of my father: Were there any health problems of self of parents? Specify: I was was not married to the father of my child I was was not married. If married, name of spouse: I was was not in a maternity home. Name of home: Address of home: What was the name of the birth father liste d in the relinquishment? His age was: His occupation was: American LegalNet, Inc. www.FormsWorkFlow.com JDF 344A R 2 - 1 8 AFFIDAVIT OF A BIRTH MOTHER WHO USED A FICTITIOUS NAME Page 2 of 2 AT THE TIME OF RELINQUISHMENT OF A CHILD If a student, what year of high school/college? His city and state of residence was: His height was: His weight was: Did he his parents have any health problems? Specify: A copy of my birth certificate is submitted with this Affidavit. By checking this box, I am acknowledging I am filling in the blanks and not changing anything else on the f orm . By checking this box, I am acknowledging that I have made a change to the original content of this form. VERIFICATION I declare und er 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 American LegalNet, Inc. www.FormsWorkFlow.com