q District Court q Juvenile Court _________________________________________ County, Colorado Court Address: In re: Petitioner: v. Respondent/Co-Petitioner: and concerning: Grandparent(s) Intervenor(s) COURT USE ONLY Attorney or Party Without Attorney (Name and Address): Case Number: Phone Number: E-mail: Division Courtroom FAX Number: Atty. Reg. #: MOTION FOR GRANDPARENT VISITATION PURSUANT TO §19-1-117, C.R.S. The intervenor(s), the q maternal q paternal grandparent(s) of the minor child(ren), hereby request(s) the Court to enter an order establishing visitation between the grandparent(s) and the child(ren), pursuant to §19-1-117, C.R.S. AND as grounds therefor, state(s) as follows: 1. Information about Intervenor (1): Date of Birth: Check if in Military q Social Security Number: _____________________________ Current Mailing Address: ___________________________________________________________________ City, State & Zip Code: _____________________________________________________________________ Home Phone #: ____________________ Work Phone #: ___________________ Cell #: _________________ Intervenor has the following relationship with the minor child(ren): q child(ren)’s grandmother, OR q child(ren)’s grandfather Information about Intervenor (2): Date of Birth: Check if in Military q Social Security Number: _____________________________ Current Mailing Address: ___________________________________________________________________ City, State & Zip Code: _____________________________________________________________________ Home Phone #: ____________________ Work Phone #: ___________________ Cell #: _________________ Intervenor has the following relationship with the minor child(ren): q child(ren)’s grandmother, OR q child(ren)’s grandfather 2. Information about the Mother: Date of Birth: q Petitioner q Respondent/Co-Petitioner Check if in Military q Social Security Number: ____________________ Current Mailing Address: ___________________________________________________________________ City, State & Zip Code: ____________________________________________________________________ Home Phone #: ____________________ Work Phone #: ___________________ Cell #: _________________ JDF 1701 R10/03 MOTION FOR GRANDPARENT VISITATION PURSUANT TO §19-1-117, C.R.S. Page 1 of 3 American LegalNet, Inc. www.FormsWorkflow.com 3. Information about the Father: Date of Birth: q Petitioner q Respondent/Co-Petitioner Check if in Military q Social Security Number: ____________________ Current Mailing Address: ___________________________________________________________________ City, State & Zip Code: _____________________________________________________________________ Home Phone #: ____________________ Work Phone #: ___________________ Cell #: __________________ 4. The name(s), address(es) and birth date(s) of the minor child(ren) is/are: Name Present Address Sex Date of Birth Soc. Sec. No. 5. The parental rights of the parents of the minor child(ren) have been terminated. q Yes q No have been terminated, please furnish the case number: __________________________________ 6. No other motions for grandparent visitation have been filed in the past two years. If other motions have been filed, state when the motion(s) was/were filed and the issue/cause for the motion(s). _______________________________________________________________________________________ If they _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ 7. Visitation with the grandparent(s) is in the child(ren)’s best interest for the following reasons: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ 8. The grandparent(s) wish(es) to have visitation with the minor child(ren) at the following times and under the following conditions: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ JDF 1701 R10/03 MOTION FOR GRANDPARENT VISITATION PURSUANT TO §19-1-117, C.R.S. Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com 9. Transportation of the child(ren) will be as follows: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ 10. List any protection/restraining orders that have been issued by any Court, in this or any other state, regarding the child(ren), the grandparent(s) or any of the parties: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ WHEREFORE, the grandparent(s) respectfully request(s) that the Court order visitation between the intervenor(s)/grandparent(s) and the minor child(ren) as set forth in this motion and any other orders necessary to effectuate the best interests of the child(ren). VERIFICATION AND ACKNOWLEDGEMENT I swear/affirm under oath that I have read the foregoing motion and that the statements set forth therein are true and correct to the best of my knowledge. _____________________________________ Signature of Grandmother Date Signature of Grandfather Subscribed and affirmed, or sworn to before me in the County of ________________________, State of ____________________, this _______ day of ________________, 20 ____. Subscribed and affirmed, or sworn to before me in the County of _________________________, State of ___________________, this ________ day of ________________, 20 ____. My commission expires: __________________ My commission expires: __________________ ______________________________________ ______________________________________ Notary Public/Clerk Notary Public/Clerk Date CERTIFICATE OF SERVICE I certify that on _______________________(date), the original and one copy of this document were filed with the Court; and, a true and accurate copy of this MOTION FOR GRANDPARENT VISITATION PURSUANT TO §19-1117, C.R.S. was served on the other parties listed in the caption by q Hand Delivery OR q Faxed to this number _______________________________________OR q by placing it in the United States mail, postage pre-paid, and addressed to the following: TO: _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ ______________________________________________ (Your signature) JDF 1701 R10/03 MOTION FOR GRANDPARENT VISITATION PURSUANT TO §19-1-117, C.R.S. 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