Page 1 of 5 JDF 559 R 3 - 1 8 DISTRICT COURT C OUNTY, COLORADO Juvenile Division Court Address: THE PEOPLE OF THE STATE OF COLORADO In the Interest of Minor Child(ren) And Concerning : Respondent . COURT USE ONLY Attorney or Party Without Attorney (Name and Address) Phone Number: Email: Fax Number: Atty Reg. #: Case Number : Division : Courtroom : RELATIVE AFFIDAVIT AND ADVISEMENT PURSUANT TO 24719 - 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 name, address and telephone number of every grandparent, aunt, uncle, brother, sister, h alf - sibling, and first cousin of the child (ren) , o ther adults with a significant relationship to your child, and also include any comments concerning the appropriateness of such person as a potential placement for the child(ren). If the child cannot be safely returned to the home of his or her parents , the Court will consider appropriate identified relatives who have a signific ant relationship with the child before making any decision regarding appropriate placement for the child. If the child cannot be safely returned to the home of his or her parents, failure to identify the relatives in a timely manner may result in the child being placed permanently outside of the home . The child may risk life - long damage to his or her emotional well - being if th e child becomes attached to The Court shall Order the County Department of Human Services to make reasonable efforts to contact appropriate and identified relatives within 30 days following the removal of the child and to inform them about placement possibilities. The attached placement information (Part II Affidavit) must be returned to the Court (within 7 days after the Temporary Custody/Shelter hearing or at the next scheduled hearing, whichever occurs first by (date). I acknowledge that I have read and understand this advisement. Signature of Parent Printed Name Date Relationship to Child(ren) American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 5 JDF 559 R 3 - 1 8 This original signed Advisement shall be filed with the Court at the Temporary Custody /Shelter Hearing and a c opy maintained by the Respondent(s) and their counsel. Case Name Case Number: PART II: AFFIDAVIT By law, this form must be filed with the Court within seven (7) days after the Temporary Custody/Shelter Hearing or at the next scheduled hearing, whichever occurs first. Please fill out blank s below. 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 ) Maternal Paternal Full Name: Relationship to Child : Home Address: Home Telephone Number: Cell Number : Email /Facebook/Twitter I want this person to be considered for placement of my child I want this person to be involved in Family Team Meetings I want this person to be involved in supporting my family, including Family Team Meetings 2. Family Member ( ) Maternal Paternal Full Name: Relationship to Child: Home Address: Home Telephone Number: Cell Number: Email/Facebook/Twitter I want this person to be considered for placement of my child I want this person to be involved in Family Team Meetings 3. Family Member ( Aunt/Uncle) Maternal Paternal Full Name: Relationship to Child: Home Address: Home Telephone Number: Cell Number: Email/Facebook/Twitter I want this person to be considered for placement of my child I want this person to be involved in Family Team Meetings Comments regard 4. Family Member ( Aunt/Uncle ) Maternal Paternal Full Name: Relationship to Child: Home Address: American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 5 JDF 559 R 3 - 1 8 Home Telephone Number: Cell Number: Email/Facebook/Twitter I want this person to be considered for placement of my child I want this person to be involved in Family Team Meetings 5 . Family Member ( Sibling) Maternal Paternal Full Name: Relationship to Child: Home Address: Home Telephone Number: Cell Number: Email/Facebook/Twitter I want this person to be considered for placement of my child I want this person to be involved in Family Team Meetings 6 . Family Member ( Sibling) Maternal Paternal Full Name: Relationship to Child: Home Address: Home Telephone Number: Cell Number: Email/Facebook/Twitter I want this person to be considered for placement of my chil d I want this person to be involved in Family Team Meetings 7 Half - Sibling) Maternal Paternal Full Name: Relationship to Child: Home Address: Home Telephone Number: Cell Number: Email/Facebook/Twitter I want this person to be considered for placement of my child I want this person to be involved in Family Team Meetings relative: - Sibling) Maternal Paternal Full Name: Relationship to Child: Home Address: Home Telephone Number: Cell Number: Email/Facebook/Twitter I want this person to be considered for placement of my child I want this person to be involved in Family Team Meetings l placement with this relative: 9. Family Member ( Cousin) Maternal Paternal American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 5 JDF 559 R 3 - 1 8 Full Name: Relationship to Child: Home Address: Home Telephone Number: Cell Number: Email/Facebook/Twitter I want this person to be considered for placement of my child I want this person to be involved in Family Team Meeting s 10. Family Member ( Cousin ) Maternal Paternal Full Name: Relationship to Child: Home Address: Home Telephone Number: Cell Number: Email/Facebook/Twitter I want this person to be considered for placement of my child I want this person to be involved in Family Team Meetings 11. Family Member ( - Grandmother ) Maternal Paternal Full Name: Relationship to Child: Home Address: Home Telephone Number: Cell Number: Email/Facebook/Twitter I want this person to be considered for placement of my child I want this person to be involved in Family Team Meetings 12. Family Member ( - Grandfather ) Maternal Paternal Full Name: Relationship to Child: Home Address: Home Telephone Number: Cell Number: Email/Facebook/Twitter I want this person to be considered for placement of my child I want this person to be involved in Family Team Meetings 1 3 . Please list any other adults who could supervise visitation, provide transportation, babysit, or call in an emergency. Home Address: Home Telephone Number: Cell Number: Email/Facebook/Twitter American LegalNet, Inc. www.FormsWorkFlow.com Page 5 of 5 JDF 559 R 3 - 1 8 Please list any other adults (example: teachers, coa ch, neighbor, etc.) and their phone numbers, who my child has a relationship with, and I want them to be considered for placement of my child: 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 acknowled ging that I have made a change to the original content of this form. VERIFICATION I declare under 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 nam e of Petitioner/Plaintiff ) Signature of Petitioner/Plaintiff Relationship to Child(ren) The Court, County Department of Human Services, each parent, the Guardian Ad Litem, and Counsel for each p arent shall receive a copy of this form. American LegalNet, Inc. www.FormsWorkFlow.com