District Court Denver Juvenile Court _________________________________County, Colorado Court Address:
IN THE MATTER OF THE PETITION OF: ______________________________ (name of person(s) seeking to adopt) FOR THE ADOPTION OF A CHILD Attorney or Party Without Attorney (Name and Address): COURT USE ONLY Case Number:
Phone Number: FAX Number:
E-mail: Atty. Reg.#:
Division
Courtroom
VERIFIED STATEMENT OF FEES CHARGED
The following fees have been charged to the Petitioner(s) relative to the adoption proceeding pursuant to ยง19-5208(4), C.R.S. and C.R.J.P. 6(b)(4): Attorney's fees: Filing fees: Publication fees: Personal service fees: Birth certificates: Hospital charges and medical fees: County department of social services fees: Child placement agency fees: Charges, gifts or charitable contributions: Other considerations or things of value: $ _______________________________ $ _______________________________ $ _______________________________ $ _______________________________ $ _______________________________ $ _______________________________ $ _______________________________ $ _______________________________ $ _______________________________ $ _______________________________ $ _______________________________
Total Fees Charged:
I have read the foregoing and that the statements set forth herein are true and correct to the best of my knowledge and belief. ______________________________________
Petitioner Signature Date
______________________________________
Petitioner Signature Date
______________________________________
Petitioner's Attorney Signature, if any
______________________________________
Petitioner's Attorney Signature, if any
Subscribed and affirmed, or sworn to before me in the County of ________________________, State of ____________________, this _______ day of ________________, 20 ____. My Commission Expires: __________________ ______________________________________
Notary Public/Deputy Clerk
JDF 454 R9/06 VERIFIED STATEMENT OF FEES CHARGED
Subscribed and affirmed, or sworn to before me in the County of _________________________, State of ___________________, this ________ day of _______________, 20 ____. My Commission Expires: __________________ ______________________________________
Notary Public/Deputy Clerk