Verified Statement Of Fees Charged
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1District 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
COURT USE ONLY
Attorney or Party Without Attorney (Name and Address):
Case Number:
Phone Number:
E-mail:
FAX Number:
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 §19-5-
208(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
Subscribed and affirmed, or sworn to before me
in the County of ________________________,
in the County of _________________________,
State of ____________________, this _______
State of ___________________, this ________
day of ________________, 20 ____.
day of _______________, 20 ____.
My Commission Expires: __________________
My Commission Expires: __________________
______________________________________
______________________________________
Notary Public/Deputy Clerk
Notary Public/Deputy Clerk
JDF 454
R9/06
VERIFIED STATEMENT OF FEES CHARGED
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