JUVENILE COURT, _____________ COUNTY, STATE OF COLORADO

No. CASE NUMBER

RESPONDENT'S ADMISSION

The State of Colorado in the Interest of:

CHILD, et. al., Children, and concerning:

RESPONDENT, et. al., Respondents.

COMES NOW Respondent RESPONDENT and admits paragraph 5(c) (or whatever) of the petition in this matter with Paragraph 6, as modified below, as the factual basis therefore and states and swears as follows:

1.     I have read the petition in this matter and I understand it.

2.     I understand I have a right to legal counsel.

3.     I understand if I am indigent I have a right to have legal counsel appointed for me.

4.     I understand I have a right to trial by jury or to the court.

5.     I understand I have a right to have the County Attorney's office prove the elements of this case in trial by a preponderance of the evidence.

6.     I understand I have the right to testify.

7.     I understand I have the right to appeal if I were to lose my trial.

8.     I understand I give up the above rights if I sign this document.

9.     I understand the court may now place the children with either parent, with family, or in foster care.

10. I understand I will be expected to participate and succeed in a Court ordered treatment plan.

11. I understand termination of parental rights is a possibility.

12. I understand that if a termination motion is filed I have a right to a separate trial, where the evidence must be clear and convincing in order for my parental rights to be terminated.

13. I understand that termination means another family would adopt the children.

14. My admission to this petition is voluntary.

15. I understand the court is not bound by any promises or representations made by anyone as to the placement of the children.

16. I am not under in the influence of drugs, medications or alcohol so that I don't understand the consequences of this document.

17. I understand the above advisement and the effects and consequences of my admission.

AND THEREFORE I ADMIT THE ALLEGATIONS OF THE PETITION in this Dependency and Neglect matter, that the children are dependent or neglected because they were in a dangerous environment (or whatever).

_________________________

RESPONDENT

Sworn and executed by RESPONDENT before me on ____________.

My Commission expires _______________.

_____________________

Notary Public