! District Court ! Denver Juvenile Court _________________________________________ County, Colorado Court Address: IN THE MATTER OF THE ADOPTION OF: AND CONCERNING: , Petitioner Attorney or Party Without Attorney (Name and Address): COURT USE ONLY Case Number: Phone Number: E-mail: FAX Number: Atty. Reg.#: Division Courtroom OATH OR AFFIRMATION OF CONFIDENTIALITY REGARDING MOTION TO OPEN ADOPTION AND RELINQUISHMENT FILES I, ________________________________________________________________________, declare under oath or affirm that: My current address is: __________________________________________________________________________________. (Street Address, City, State, Zip) My current telephone numbers are: (Home) ________________________________ (Work) ___________________________ I agree, until further written notice to the Court, to accept appointment as a confidential intermediary in cases where the petitioner is seeking to find birth relatives. I state that I am not seeking appointment on behalf of a relative, friend, business associate, or other individual that could constitute a conflict of interest. I affirm that: 1. Any information I obtain during the course of my investigation shall be kept strictly confidential and shall be used only for the purpose of arranging a contact between the individual who initiated the search and the sought-after biological relative or for release of information pursuant to §19-5-305(2)(a)(II) and (2)(c)(I), C.R.S.; 2. When a sought-after biological relative is located on behalf of the petitioner, I shall obtain consent from both parties that they wish to personally communicate with one another or for release of information pursuant to §19-5-305(2)(a)(II) and (2)(c)(I), C.R.S.; 3. Contact shall be made between the petitioner and sought-after party only when consent for such contact has been received by the Court; 4. If consent for personal communication is not obtained from both parties, all relinquishment and adoption records and any other information I obtained shall be returned to the Court and shall remain confidential, except as provided by §19-5305(2)(a)(II) and (2)(c)(I), C.R.S.; and 5. If appointed by the Court as a confidential intermediary, I will make no unreasonable charges for my services, and will include a copy of my itemized fees and expenses in my report to the Court. Date: _______________________________________ ___________________________________________ Chief Confidential Intermediary For: _________________________________________ Training Organization SUBSCRIBED under oath before me on ________________________in the County of ______________________________, (date) State of ________________________________. My commission expires: ________________________ JDF 340 R9/00 ___________________________________________ Notary Public OATH OR AFFIRMATION OF CONFIDENTIALITY BY CHIEF CONFIDENTIAL INTERMEDIARY 2001 © American LegalNet, Inc.