JDF 404 R 2 - 1 8 AFFIDAVIT REGARDING CHILDREN PURSUANT TO 24714 - 13 - 209, C.R.S. Page 1 of 2 Municipal Court County Court District Court Denver Juvenile Denver Probate County, Colorado Court Address: Petitioner: v. Respondent: COURT USE ONLY Attorney or Party Without Attorney (Name and Address): Phone Number: E - mail: FAX Number: Atty. Reg. #: Case Number: Division Courtroom AFFIDAVIT REGARDING CHILDRE N PURSUANT TO 24714 - 13 - 209, C.R.S. I (name of party) submit the following information to the Court: 1. address will endanger the minor children. 2. The minor children are (list full name and date of birth): (Do not include address if number 1 ab ove is checked.) Full Name of Child Date of Birth Current Address 3. The above - named children have lived with the following persons and in the following places within the last five years: (Give name and address of all persons the childr en have lived with within the last five years.) Name of Party Address (City/State/Zip Code) Time Period (Month/Year) Relationship to Child 4. A legal action for Dissolution of Marriage or Civil Union , Legal Separation, Paternity, o r Allocation of Parental Responsibilities (Decision - Making and Parenting Time) with the above - named children identified in the action has has not been filed. If such an action has been filed, complete the information below: County Where Case Has Been F iled State Case Number Nature of Proceeding 5. I have have not participated as a party or witness or in any other capacity in any other court proceeding concerning custody of, or visitation, or parenting time with the above - named children in this or any other state. If so, please provide the following information. American LegalNet, Inc. www.FormsWorkFlow.com JDF 404 R 2 - 1 8 AFFIDAVIT REGARDING CHILDREN PURSUANT TO 24714 - 13 - 209, C.R.S. Page 2 of 2 County Where Case Has Been Filed State Case Number Date of Hearing 6. I do do not know of any court proceedings that could affect this proceeding, including pro ceedings concerning enforcement of prior orders, domestic violence/abuse, protective/restraining orders, termination of parental rights, or adoption. If so, please provide the following information. County Where Case Has Been Filed State Case Number Nat ure of Proceeding 7. I do do not know of any person not a party to the proceeding who has physical custody or claims rights of parental responsibilities, legal custody, physical custody, visitation or parenting time with the above - named children. If yes, please provide the fol lowing information. Name of Person Address (Street, City, State, Zip Code) 8. I do do not understand that I have a continuing duty to inform the Court of any custody proceedings concerning the children in this or any other state when I obtain su ch information during this proceeding. 9. I am am not a Native American Indian and these children are are not subject to the provisions of the Indian Child Welfare Act. By checking this box, I am acknowledging I am filling in the blanks and not chang ing 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 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 (printed name of Petitioner Respondent) Signature of Petitioner Respondent American LegalNet, Inc. www.FormsWorkFlow.com