JDF 17 01 R 3 - 1 8 PLEADING AFFIDAVIT FOR GRANDPARENT /GREAT - GRANDPARENT VISITATION PURSUANT TO 24719 - 1 - 117, C.R.S. Page 1 of 4 District Court Juvenile Court County, Colorado Court Address: In re: The Marriage of: The Civil Union of: Parental Responsibilities concerning: Petitioner: a nd Co - Petitioner/ R espondent: and concerning: Grandparent(s) Great - Grandparent(s) Intervenor(s) : COURT USE ONLY Attorney or Party Without Attorney (Name and Address) : Phone Number: E - mail: FAX Number: Atty. Reg. #: Case Number: Division Courtroom VERIFIED PLEADING AFFIDAVIT FOR GRANDPARENT GREAT - GRANDPARENT VISITATION PURSUANT TO 24719 - 1 - 117, C.R.S. AND RULE 24 OF THE COLORADO RULES OF CIVIL PROCEDURE Note to Responding Party: If you disagree with this Pleading Affidavit , the Colorado Civil Rules of Procedure allow you to file a written response with the Court which must be filed within 21 days of the date this Pleading Affidavit was served on you or m ailed to you. The intervenor(s), the maternal paternal grandparent(s) great - grandparent(s) of the minor child(ren), states the following for the purpose of establishing visitation between the grandparent(s) great - grandparent(s) and the child(ren), pursuant to 24719 - 1 - 117, C.R.S. A Pleading A ffidavit seeking an Order for grandparent /great - grandparent visitation has has not been filed in the last two years. If one has been filed, please identify the date filed and stat e in section 8 below, the reasons why you believe you have good cause to now file again for visitation . 1. Information about Intervenor (1): Check if in Military Full Legal Name: Date of Birth: Current Mailing Address: City : State: Zip Code: Home Phone #: Email Address: Cell Phone #: Intervenor has the following relationship with the minor child(ren): - grandmother - grandfather American LegalNet, Inc. www.FormsWorkFlow.com JDF 17 01 R 3 - 1 8 PLEADING AFFIDAVIT FOR GRANDPARENT /GREAT - GRANDPARENT VISITATION PURSUANT TO 24719 - 1 - 117, C.R.S. Page 2 of 4 2. Information about Intervenor (2): Check if in Military Full Legal Name: Date of Birth: Current Mailing Address: City: State: Zip Code: Home Phone #: Email Address: Cell Phone #: Intervenor has the following relationship with the minor child( ren): - grandmother - grandfather 3. Information about the Mother: Petitioner Respondent/Co - Petitioner Check if in Military Full Legal Name: Current M ailing Address: City: State: Zip Code: Home Phone #: Email Address: Cell Phone #: 4. Information about the Father: Petitioner Respondent/Co - Petitioner Check if in Military Full Legal Name: Current Mailing Address: City: State: Zip Code: Home Phone #: 5. The minor child(ren) is/are : Full Name of Child Present Address Sex Date of Birth 6. The parental rights of the parents of the minor child(ren) have been terminated. Yes No If Yes , please furnish the case number: 7. Visitation with the grandparent(s) great - grandparent(s) reasons: American LegalNet, Inc. www.FormsWorkFlow.com JDF 17 01 R 3 - 1 8 PLEADING AFFIDAVIT FOR GRANDPARENT /GREAT - GRANDPARENT VISITATION PURSUANT TO 24719 - 1 - 117, C.R.S. Page 3 of 4 8. The grandparent(s) great - grandparents(s) wish(es) to have visitation with the minor child(ren) at the following times and under the following conditions: 9. Transportation of the child(ren) will be as follows: 10. Have any Temporary or Permanent Protection/Restraining Orders or any Criminal Mandatory P rotection/Restraining Orders (MRO) or Emergency Protection Orders been issued against the grandparent(s) /great - grandparent(s) or any of the parties within two years prior to the filing of this Petition? No Yes If your answer was Yes , complete the follo wing: The Protection/Restraining Order was Temporary Permanent MRO and issued against in a Municipal Court County Court District Court in the County of , State of , in case number on (date) . What was the subject matter of the Protection/Restraining Order or Emergency Protection Order? I/We respectfully request that this Court enter an Order for v is itation between the intervenor(s)/grandparent(s) Intervenor(s)/great - grandparent(s) and the minor child(ren) as set forth in this Pleading Affidavit and any other orders necessary to effectuate the best interests of the child(ren). I/We respectfully request a hearing before the Court before an order is entered. (Optional) American LegalNet, Inc. www.FormsWorkFlow.com JDF 17 01 R 3 - 1 8 PLEADING AFFIDAVIT FOR GRANDPARENT /GREAT - GRANDPARENT VISITATION PURSUANT TO 24719 - 1 - 117, C.R.S. Page 4 of 4 By checking this box, I am acknowledging I am filling in the blanks and not changing anything else on the form. By checking this box, I am acknowledging that I have made a change to the original content of this form. VERIFICATION AND ACKNOWLEDGEMENT I (name) swear/affirm under oat h , and under penalty of perjury, that I have read the foregoing Verified Pleading Affidavit for Grandparent /Great - Grandparent Visitation Pursuant to 24719 - 1 - 117, C.R.S. and Rule 24 of the Colorado Rules of Civil Procedure and that the statements set forth th erein are true and correct to the best of my knowledge and belief . Signature of Grandmother Date Signature of Grandfather Date Signature of Great - Grandmoth er Signature of Great - Grandfather Attorney Signature, if any Attorney Signature, if any The foregoing instrument was s ubscribed and The foregoing instrument was subscribed and affirmed, or sworn before me in the County of affirmed, or sworn before me in the County of , State of Colorado, , State of Colorado, this day of , 20 this day of , 20 by by My Commission Expires: My Commission Expires: Notary Public/ Deputy Clerk Notary Public/ Deputy Clerk CERTIFICATE OF SERVICE I certify that on (date) a true and accurate copy of th is Verified Pleading Affidavit for Grandparent /Great - Grandparent Visitation Pursuant to 24719 - 1 - 117, C.R.S. and Rule 24 of the Colorado Rules of Civil Procedure was served on the other party by: Hand Delivery, E - filed, Faxed to this number , or by placing it in the United States mail, postage pre - paid, and addressed to the following: T o : Signature American LegalNet, Inc. www.FormsWorkFlow.com