Colorado > Statewide > Confidential Intermediary
Affirmation Of A Birth Mother Who Used A Fictitious Name At Time Of Relinquishment Of Child JDF 344A - Colorado
| Affirmation Of A Birth Mother Who Used A Fictitious Name At Time Of Relinquishment Of Child Form. This is a Colorado form and can be used in Confidential Intermediary Statewide . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
! District Court ! Denver Juvenile Court _________________________________________ County, Colorado Court Address: IN THE MATTER OF THE ADOPTION OF: Birth Name of Adoptee (If known) AND CONCERNING COURT USE ONLY Case Number: Current Legal Name of Petitioner Attorney or Party Without Attorney (Name and Address): Phone Number: FAX Number: E-mail: Atty. Reg.#: Division Courtroom AFFIDAVIT OF A BIRTH MOTHER WHO USED A FICTITIOUS NAME AT THE TIME OF RELINQUISHMENT OF A CHILD I, _______________________________________________________________________________, declare under oath that: My current address is: __________________________________________________________________________________. (Street Address, City, State, Zip) My date of birth is: ________________________________ My current telephone numbers are: (Home) ________________________________ (Work) ___________________________ At the time of the relinquishment of my child, I used the alias: My legal name at the time of the relinquishment was: My maiden name was: At relinquishment my child's name was: ______ _____ !"Fictitious !"Non-Fictitious surname. If known, what was the name of the agency awarded custody of the child? ________________________________________ If known, adoption agency handling relinquishment/termination: _________________________________________________ At relinquishment my age was: ___________ My occupation was: _______________________________________________ If a student, what year of high school/college? My city and state of residence was: My height was: My parents My weight was: were aware ! ! ! were unaware of my pregnancy. __ of self Name of my father: ______ Name of my mother: Were there any health problems ! of parents? Specify: _______________________________________ I I I ! ! ! was was was ! ! ! was not married to the father of my child was not married. If married, name of spouse: was not in a maternity home. Name of home: Address of home: What was the name of the birth father listed in the relinquishment? His age was: JDF 344A R9/00 ___ His occupation was: AFFIDAVIT OF A BIRTH MOTHER WHO USED A FICTITIOUS NAME AT THE TIME OF RELINQUISHMENT OF A CHILD Page 1 of 2 ______________ 2001 © American LegalNet, Inc. If a student, what year of high school/college? His city and state of residence was: His height was: Did His weight was: ! he ! his parents have any health problems? Specify: fjaklf A copy of my birth certificate is submitted with this Affidavit. Date: __________________________________________ ___________________________________________ Petitioner SUBSCRIBED under oath before me on ________________________in the County of ______________________________, (date) State of ________________________________. My commission expires: ________________________ ___________________________________________ Notary Public JDF 344A R9/00 AFFIDAVIT OF A BIRTH MOTHER WHO USED A FICTITIOUS NAME AT THE TIME OF RELINQUISHMENT OF A CHILD Page 2 of 2 2001 © American LegalNet, Inc.
|
|||||||
