District Court ____________________________ County, Colorado

Court Address:

In re the Marriage of:

Petitioner:
and
COURT USE ONLY
Co-Petitioner/Respondent:
Attorney or Party Without Attorney (Name and Address): Case Number:

Phone Number: E-mail:

FAX Number: Atty. Reg. #: Division Courtroom

Petition for: Dissolution Legal Separation

If Children Are Part of This Action, Please Check Here 

1. This petition is filed pursuant to C.R.S. § 14-10-106.

2. The Marriage is irretrievably broken.

3. Information about the Petitioner: Check if in Military

Full Legal Name: ___________________________________________ Date of Birth: _________________

Length of Current Residency in Colorado: (Years/months) Dates:

Current Mailing Address: Apt.#________

City: State: Zip Code: ___________ Home Phone #:

Email Address: _______________________________ Cell Phone #:

4. Information about the Co-Petitioner/Respondent: Check if in Military

Full Legal Name: ___________________________________________ Date of Birth: _________________

Length of Current Residency in Colorado: (Years/months) Dates:

Current Mailing Address: Apt.#________

City: State: Zip Code: ___________ Home Phone #:

Email Address: ______________________________ Cell Phone #:

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5. Date of the Marriage: ___________________ Place of Marriage: __________________________ (City/State)

6. Date the parties separated: ______________________

7. A party to the marriage is presently expecting a child not presently expecting a child

8. The following child(ren) was/were born or adopted of this marriage. (attach a second sheet, if necessary):
Full Name of Child Present Address Sex Date of Birth

9. Regarding the Indian Child Welfare Act (ICWA):

 I am aware of the child or child’s relatives having American Indian/Native American or Alaska Native
ancestry.

Name of tribe(s)

NOTE: If you checked that you are “aware” of the child or child’s relatives having any American Indian/Native
American or Alaska Native ancestry, you must complete and file with the court, JDF1350 – Indian Child
Welfare Act (ICWA) Assessment Form.

 I am not aware of the child or child’s relatives having any American Indian/Native American or Alaska
Native ancestry.

10. The child(ren) listed above have lived in Colorado for a minimum of 182 days prior to the filing of this Petition
or since birth if under six months of age. Yes No If No, please state the name of child, name of person
child lived with and the month, date and year when each child most recently moved to Colorado.

Full Name of Child Name of Person Child Lived State Moved Month Day Year
with From

11. I/We understand that a request for genetic tests shall not prejudice the requesting party in matters concerning
allocation of parental responsibilities pursuant to §14-10-124(1.5), C.R.S. If genetic tests are not obtained
prior to a legal establishment of paternity and submitted into evidence prior to the entry of the final decree of
dissolution or legal separation, the genetic tests may not be allowed into evidence at a later date.

12. Each party has a continuing duty to inform the Court of any proceeding in this or any other state that
could affect the current proceeding.

13. I/We understand that the Court may review any case involving the children, Petitioner, Co-Petitioner/
Respondent and other parties named in this Petition that have been filed in any Court.

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14. I/We have participated in the following proceeding(s) regarding the child(ren) as a party or a witness, or in any
other capacity concerning the allocation of parental responsibilities including decision-making, child support
and parenting time with the child(ren). Identify name of court, case number, state, date, and type of
proceeding if any.

Name of Court Case Number State Date of Proceeding Type of Proceeding

15. I/We know of the following proceeding(s) that could affect the current proceeding including, but not limited to
proceedings relating to domestic violence or domestic abuse, enforcement of Court orders,
protection/restraining orders, termination of parental rights, and adoptions. Identify name of court, case
number, state, date, and type of proceeding if any.

Name of Court Case Number State Date of Proceeding Type of Proceeding

16. The following people are not parties in this matter, but have physical custody of the child(ren) or claim rights
of parental responsibilities, legal custody or physical custody, or visitation/parenting time with the child(ren).
Identify name and address of those persons, if any.

Full Name of Person Address (Street, City/State, Zip Code)

17. Required Notice of Human Services Involvement.

The parents or dependent child(ren) listed on this Petition has/have received within the last five years, or
is/are currently receiving benefits or public assistance from the state Department of Human Services or the
County Department of Social Services. No Yes If your answer was Yes, complete the following:

Name of Person Receiving Benefit Name of County and State Case Number Month/Year

18. Required Notice of Prior Protection/Restraining Orders.

Have any Temporary or Permanent Protection/Restraining Orders to prevent domestic abuse or any Criminal
Mandatory Protection/Restraining Orders (MRO) or Emergency Protection Orders been issued against either
party within two years prior to the filing of this Petition?

No Yes If your answer was Yes, complete the following:

The Protection/Restraining Order was Temporary Permanent MRO and issued against

______________________________ in a Municipal Court County Court District Court in the County of

______________, State of ______________, in case number _______________ on ______________ (date).

What was the subject matter of the Protection/Restraining Order or Emergency Protection Order?

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19. Notice of Existing Case with Child Support Enforcement (CSE)
The parents have filed a case with CSE? No Yes If Yes, identify the case number: _____________

20. I/We ask that the Court enter orders regarding the status of the marriage, best interests of the child(ren),
maintenance (spousal support) child support, division of property and debts, attorney fees and costs, if
appropriate, restoration of the previous name of a party, and any other necessary orders.

21. The Petitioner Co-Petitioner requests that the Court restore his/her prior full name to
______________________________________.

Notice: Colorado Revised Statutes §14-10-107, provides that upon the filing of a Petition for Dissolution of
Marriage or Legal Separation by the Petitioner and Co-Petitioner, or upon personal service of the Petition and
Summons on the Respondent, or upon waiver and acceptance of service by the Respondent, an automatic
temporary injunction shall be in effect against both parties until the Final Decree is entered, or the Petition is
dismissed, or until further Order of the Court. Either party may apply to the Court for further temporary orders, an
expanded automatic temporary injunction, or modification or revocation under §14-10-108, C.R.S. or any other
appropriate statute.

1. Both parties are restrained from transferring, encumbering, concealing, or in any way disposing of,
without the consent of the other party, or an Order of the Court, any marital property, except in the
usual course of business or for the necessities of life. Each party is required to notify the other party
of any proposed extraordinary expenditures and to account for all extraordinary expenditures made
after the injunction is in effect; and

2. Both parties are enjoined from molesting or disturbing the peace of the other party or the minor
child(ren); and

3. Both parties are restrained from removing the minor child(ren) of the parties, if any, from the state
without the consent of the other party or an Order of the Court; and

4. Both parties are restrained, without at least 14 days advance notification and the written consent of
the other party or an Order of the Court, from canceling, modifying, terminating, or allowing to lapse
for nonpayment of premiums, any policy of health insurance, homeowner’s or renter’s insurance, or
automobile insurance that provides coverage to either of the parties or the minor child(ren) or any
policy of life insurance that names either of the parties or the minor child(ren) as a beneficiary.

Nothing in this automatic injunction shall prohibit either party from applying to the Court for
further orders, an expanded automatic temporary injunction, or orders modifying or revoking
this injunction.
Petitioner and Co-Petitioner, if any, acknowledge that he or she has received a copy of, has
read, and understands the terms of the automatic temporary injunction set forth in this Petition
and the Summons.

 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 acknowledging that I have made a change to the original content of this form.
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 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) Signature of Petitioner

____________________________________
Attorney Signature ( if any)

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 Co-Petitioner) Signature of Co-Petitioner

____________________________________
Attorney Signature ( if any)

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