District Court Denver Juvenile Court ____________________________________County, Colorado Court Address: The People of the State of Colorado In the interest of: _________________________________________ Child(ren) and Concerning _________________________________________ Respondent(s) Attorney or Party Without Attorney (Name and Address): ▲ COURT USE ONLY ▲ Case Number: Phone Number: E-mail: Division Courtroom FAX Number: Atty. Reg. #: AFFIDAVIT AND ADVISEMENT CONCERNING THE CHILD’S POTENTIAL PLACEMENT PURSUANT TO §19-3-403, C.R.S. PART I: ADVISEMENT TO EACH PARENT ATTENDING A TEMPORARY CUSTODY HEARING. This matter comes before the Court on ___________________________ (date). The Court hereby advises the parent(s) in this case of the following: You are required to fill out the below placement information (Part II – Affidavit) fully and completely under penalties of perjury and contempt of court. You are required to list the names, addresses and telephone numbers of every grandparent, aunt, uncle, brother, sister, half-sibling, and first cousin of the child, and any comments concerning the appropriateness of the child’s potential placement with each person. If the child cannot be safely returned to the parents’ home, the Court may place the child with appropriate identified relatives who have a significant relationship with the child. If the child cannot be safely returned to the home of the child’s parents, failure to identify the relatives in a timely manner may result in the child being placed permanently outside of the home of the child’s relatives who have a significant relationship with the child. The child may risk life-long damage to his or her emotional well-being if the child becomes attached to one caregiver and is later removed from the caregiver’s home. The Court may Order the County Department of Social Services to contact appropriate identified relatives within 90 days after the hearing to inform them about placement possibilities. The attached placement information (Part II – Affidavit) must be returned to the Court by ______________ (date). I acknowledge that I have read and understand this advisement. Date: __________________________________ ______________________________________ Signature of Parent Date: __________________________________ ______________________________________ Signature of Parent This original signed Advisement shall be filed with the Court at the Temporary Custody Hearing and a copy maintained by the Respondent(s) and their counsel. JDF 559 7/05 AFFIDAVIT AND ADVISEMENT CONCERNING THE CHILD’S POTENTIAL PLACEMENT Page 1 of 3 American LegalNet, Inc. www.USCourtForms.com Case Name _____________________ v. ______________________ Case Number: ___________________ PART II: AFFIDAVIT Must be filed with the Court no later than fifteen (15) days after the Temporary Custody Hearing or prior to the next scheduled hearing, whichever occurs first. Please list the names, addresses and telephone numbers of the child’s relatives, both paternal and maternal, including grandparent(s), aunt(s), uncle(s), brother(s), sister(s), half-sibling(s), and first cousin(s), and provide any comments of the child’s potential placement with each person. Each Respondent shall complete a separate Affidavit. I, __________________________________________, a parent in this action, being duly sworn and upon oath, respond as follows to the requested information. 1. Family Member Full Name: _____________________________________________ Relationship: ________________________ Home Address: _____________________________________________________________________________ Mailing Address: ____________________________________________________________________________ Home Telephone Number: ___________________________ Cell Number: ______________________________ Comments regarding the appropriateness of the child’s potential placement with this relative: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 2. Family Member Full Name: _____________________________________________ Relationship: ________________________ Home Address: _____________________________________________________________________________ Mailing Address: ____________________________________________________________________________ Home Telephone Number: ___________________________ Cell Number: ______________________________ Comments regarding the appropriateness of the child’s potential placement with this relative: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 3. Family Member Full Name: _____________________________________________ Relationship: ________________________ Home Address: _____________________________________________________________________________ Mailing Address: ____________________________________________________________________________ Home Telephone Number: ___________________________ Cell Number: ______________________________ Comments regarding the appropriateness of the child’s potential placement with this relative: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 4. Family Member Full Name: _____________________________________________ Relationship: ________________________ Home Address: _____________________________________________________________________________ JDF 559 7/05 AFFIDAVIT AND ADVISEMENT CONCERNING THE CHILD’S POTENTIAL PLACEMENT Page 2 of 3 American LegalNet, Inc. www.USCourtForms.com Mailing Address: ____________________________________________________________________________ Home Telephone Number: ___________________________ Cell Number: ______________________________ Comments regarding the appropriateness of the child’s potential placement with this relative: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 5. Family Member Full Name: _____________________________________________ Relationship: ________________________ Home Address: _____________________________________________________________________________ Mailing Address: ____________________________________________________________________________ Home Telephone Number: ___________________________ Cell Number: ______________________________ Comments regarding the appropriateness of the child’s potential placement with this relative: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 6. Family Member Full Name: _____________________________________________ Relationship: ________________________ Home Address: _____________________________________________________________________________ Mailing Address: ____________________________________________________________________________ Home Telephone Number: ___________________________ Cell Number: ______________________________ Comments regarding the appropriateness of the child’s potential placement with this relative: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ (Attach more sheets if necessary.) I/We swear under penalty of perjury that the above information is true and correct to the best of my knowledge and is a full and true disclosure of all information that is requested. _____________________________________ ______________________________________ Parent Signature Parent Signature Date Date 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 The County Department of Social Services, each parent, the Guardian Ad Litem, and Counsel for each parent shall receive a copy of this form. JDF 559 7/05 AFFIDAVIT AND ADVISEMENT CONCERNING THE CHILD’S POTENTIAL PLACEMENT Page 3 of 3 American LegalNet, Inc. www.USCourtForms.com