Resources - A Practical Guide to the Indian Child Welfare Act; Native American Rights Fund

Tenn. Comp. R. & Regs. 0250-7-13-.03

TENNESSEE RULES AND REGULATIONS

0250. TENNESSEE DEPARTMENT OF CHILDREN'S SERVICES

0250-7. SOCIAL SERVICES DIVISION

CHAPTER 0250-7-13. ADOPTION PROCESS FORMS

0250-7-13-.03. SURRENDER DOCUMENTS FOR USE IN SURRENDERS TO A TENNESSEE LICENSED CHILD-PLACING AGENCY OR THE TENNESSEE DEPARTMENT OF CHILDREN'S SERVICES IN THESE MATTERS, IN A TENNESSEE COURT.

(1) The following form is composed of four (4) Parts making a complete package which must be used at the time of surrender of a child for adoption in a Tennessee court to a Licensed Child-Placing Agency (LCPA) or the Tennessee Department of Children's Services in these matters, (TDCS). Parts I, II, and III must be completed at the time of the surrender. Copies of Parts I and II should be given to the person executing the surrender and to the Department or LCPA. Copies of Part III should be given to the person executing the surrender and sent directly to the Department's Central Office by the Clerk. Part IV, the revocation of surrender, which is part of the package, must be given to the parent or guardian at the time of the surrender.

(2) The requirements for execution and processing of the forms are contained in T.C.A. §§ 36-1-111 and 36-1-112 and are noted in summary manner on the forms.

(3) The information in these forms is confidential and is not to be released without the written approval of the court.

(4) Form:

FORMS FOR SURRENDER IN TENNESSEE OF A CHILD TO TENNESSEE DEPARTMENT OF

CHILDREN'S SERVICES OR A LICENSED CHILD-PLACING AGENCY BY A PARENT OR GUARDIAN

IN TENNESSEE

PART I

PRE-SURRENDER INFORMATION

The following information is required by Tennessee Code Annotated § 36-1- 111 and must be obtained under oath by the Court prior to execution of the surrender in PART II by the parent or legal guardian:

Note: Pseudonyms must not be used nor may spaces for the identities of persons whose names are known be left blank. The court shall require the persons executing these documents to prove their identities satisfactorily to the court. T.C.A. § 36-1-111(g).

STATE OF _________ )

COUNTY OF ________ )

Being duly sworn according to law, affiant would state:

1. I am:

a. Mother: __________________ (Date of Birth) _____, or

b. Father: __________________ (Date of Birth) _____, or

c. Legal Guardian: _______________ (Date of Birth) _____, of:

2. a. Child's Name _____________________

b. Child's Date of Birth __________________

c. Child's Place of Birth __________________

d. Child's Sex _____________________

e. Child's Race _____________________

3. This child was born in wedlock [ ] / out of wedlock[ ].

4. State the names and relationships of any other legal/biological parent, legal guardian or possible biological parent for this child:

a. (1) Name: ________________________

(2) Relationship to the child: __________________

(3) Address ________________________

(4) City, State Zip _____________________

(5) Telephone Number: Home: _________ Work: ________

(6) Other identifying information concerning the above identified other legal or biological parent/legal guardian.

_________________________________

_________________________________ and

b. (1) Name: ________________________

(2) Relationship to the child: __________________

(3) Address ________________________

(4) City, State Zip _____________________

(5) Telephone Number: Home: _________ Work: ________

(6) Other identifying information concerning the above identified other legal or biological parent or legal guardian.

_________________________________

_________________________________ and

c. (1) Name: ________________________

(2) Relationship to the child: __________________

(3) Address ________________________

(4) City, State Zip _____________________

(5) Telephone Number: Home: _________ Work: ________

(6) Other identifying information concerning the above identified other legal or parent/legal guardian.

_________________________________

5. The identity is unknown for the other:

a. Legal parent Yes [ ] No [ ]

b. Biological parent Yes [ ] No [ ]

c. Legal guardian Yes [ ] No [ ]

d. Not applicable Yes [ ] No [ ]

6. The whereabouts is unknown for the other:

a. Legal parent Yes [ ] No [ ]

b. Biological parent Yes [ ] No [ ]

c. Legal guardian Yes [ ] No [ ]

d. Not applicable Yes [ ] No [ ]

7. I state that all information concerning the identity, whereabouts, and social and medical history concerning the above-named legal or biological parent/legal guardian has been ( ___ ) or will be given ( ___ ) to the Tennessee Department of Children's Services or the Licensed Child-Placing Agency to whom the above child is being surrendered.

8. Information Concerning Child's Native American Heritage:

a. Are you or the child of Native American heritage? Yes [ ] No [ ]

If no, go to # 9.

b. If yes, are you eligible for tribal membership? Yes [ ] No [ ]

c. If yes, give name of tribe. ____________________

d. Are you registered with a Native American tribe? Yes [ ] No [ ]

e. If yes, give name of tribe. ____________________

f. Is your child eligible for tribal membership? Yes [ ] No [ ]

g. If yes, give name of tribe. ____________________

h. Has your child been registered with a Native American Yes [ ] No [ ]

tribe?

i. If yes, give name of tribe. ____________________

j. This information is unknown. Yes [ ] No [ ]

9. a. Will this child be sent out of Tennessee to another state or country for adoption?

Yes [ ] No [ ] If no, go to #10

b. If yes, name of state or country.

___________________________

c. If yes, I understand Tennessee law will govern the interpretation of this surrender.

10. Have you been paid, received or been promised any money or other remuneration of thing of value in connection with the birth of the above-named child or placement of this child for adoption? Yes [ ] No [ ]

If no, go to #11.

If yes, please complete the following:

Amount Paid To Whom By Whom Date Received/Paid Type Service/Cost

--------------------------------------------------------------------

11. a. Does the child own any real or personal property? Yes [ ] No [ ] If yes, please describe the property owned and give the property value: ________

____________________________________________________________________________

_______________________________________

b. Is it expected that the child will become possessed of any real or personal property? Yes [ ] No [ ]

If, yes please describe property, who currently owns the property, the time and circumstances under which the child becomes owner and give the property value:

____________________________________________________________________________

______________________________________

12. a. Do you currently have:

Only legal custody of the child? Yes [ ] No [ ]

Only physical custody of the child? Yes [ ] No [ ]

Both legal and physical custody of the child? Yes [ ] No [ ]

b. If another person(s) holds legal custody of the child at this time, give the following information:

Name: ______________________________

Relationship, if any, to you or the child: _____________________

Address: ________________________________

(Street, RR, P.O. Box) (Town/City) (State) (Zip)

Telephone Number (Home) ____ (Work) ____

c. If another person(s) holds physical custody of the child at this time, give the following information:

Name: ______________________________

Relationship, if any, to you or the child: ____________________

Address: ______________________________

(Street, RR, P.O. Box) (Town/City) (State) (Zip)

Telephone Number (Home) ____ (Work) ____

d. Is the person(s) who holds custody the prospective adoptive parent? Yes [ ] No [ ]

e. If a licensed child placing agency, the Department of Children's Services or another State agency holds physical and/or legal custody of your child, give the following information:

Name of Agency: ___________________________

Street/Rural Route/P.O. Box: ________________________

Town/City: _______________ State: _________ Zip: ___

f. Do you intend to give custody to the licensed child placing agency or the Tennessee Department of Children's Services? Yes [ ] No [ ]

g. Explain any other circumstances regarding the custody status of this child: ________

_________________________________

13 a. Are you aware of assistance which may be available to you to care for the child should you desire to parent this child? Yes [ ] No [ ]

b. Do you desire counseling regarding such assistance which may be available to you or regarding other issues surrounding adoption or parenting from the Tennessee Department of Children's Services a licensed child-placing agency, or a licensed clinical social worker concerning the decision to place this child for adoption? Yes [ ] No [ ]

c. Has such counseling been made available to you? Yes [ ] No [ ]

14. a. Do you desire to be represented by legal counsel at this surrender proceeding? Yes [ ] No [ ]

b. If not, do you desire to consult with legal counsel prior to the execution of the surrender of the child? Yes [ ] No [ ]

c. Has such counseling been made available to you? Yes [ ] No [ ]

15. Do you understand that if you sign the following surrender of the above- named child that you will have no right to act as parent of the child in any manner forever, that your rights and responsibilities to and with the child will be terminated and that the child will become the legal child of other persons? Yes [ ] No [ ]

16. a. If you sign the surrender of the above-named child, do you understand that within ten (10) days from the date you sign the surrender, you may revoke or cancel this surrender by signing a paper called a REVOCATION OF SURRENDER before the judge who is here today, or his or her successor? Yes [ ] No [ ]

b. By signing the surrender of the above named child on this date, (Mo/Day/Yr) ______, the period of revocation of the surrender will begin on the day following the signing of the surrender, or (Mo/Day/Yr) _________. The revocation period is ten (10) calendar days and will expire on the tenth (10th) day or (Mo/Day/Yr) _________. If the tenth (10th) day falls on a Saturday, Sunday or legal holiday, the last day for revocation will be the next day which is not a Saturday, Sunday or legal holiday. If this is the situation in this case, that date will be (Mo/Day/Yr) ________ Do you understand this? Yes [ ] No [ ]

c. Do you understand that if you do sign the Revocation of Surrender form within the ten (10) day period, the Tennessee Department of Children's Services or Licensed Child-Placing Agency will be required to return the child, if you currently have custody of the child, unless the court finds that to do so will likely result in immediate harm to the health and safety of the child, and that you may contest this decision not to return the child to you and you may have legal counsel to represent you in that proceeding? Yes [ ] No [ ]

17. Knowing the above, do you freely, voluntarily and without duress or pressure by any other person(s) desire to surrender the above-named child so that the child may be placed for adoption and adopted by other persons? Yes [ ] No [ ]

FURTHER, AFFIANT SAITH NOT.

This the ___ day of ____ 20 ___.

Signature: Biological ___ Legal ___ Mother __________________

Biological ___ Legal ___ Father __________________

Legal Guardian ______________________ of

___________________________

Name of Child

Sworn to and subscribed before me this the ___ day of ___, 20 ___.

Please Print: _____________________

___ Chancellor, ___ Circuit Judge, or ___ Juvenile Court Judge

of __________ County, Tennessee

Signature: _____________________

Chancellor, Circuit Judge, or Juvenile Court Judge

PART II

A. SURRENDER BY PARENT OR GUARDIAN TO THE TENNESSEE DEPARTMENT OF CHILDREN'S SERVICES OR A LICENSED CHILD-PLACING AGENCY AND ACCEPTANCE OF THE SURRENDER BY THE TENNESSEE DEPARTMENT OF CHILDREN'S SERVICES OR LICENSED CHILD-PLACING AGENCY

STATE OF TENNESSEE

COUNTY OF ____________

Being duly sworn according to law, affiant would state:

1. I am:

a. Mother: _______________ or

b. Father: _____________ ___, or

c. Legal Guardian: ____________ of:

2. a. Child's Name: _______________

b. Child's Date of Birth: ____________

c. Child's Place of Birth: ____________

d. Child's Sex: _______________

e. Child's Race: _______________

3. I understand that by my signature to this document, all of my parental or guardianship rights to the child named above will be forever terminated and ended; that this child will be placed for adoption by ______________________, a Licensed Child-Placing Agency, or ___ by the Tennessee Department of Children's Services and that the child will be adopted by other persons, and that I will have no further right to see this child, or to act as parent of this child, or to otherwise be involved in the life of this child.

4. I understand that by signing this document, I will not be entitled to any notice, legal or otherwise, of any other legal proceedings for the adoption of my child by other persons.

5. a. I have read and fully understand Part I of this document and fully understand that if I change my decision to surrender this child I must do so by ____ (Date from # 16b. of Part I) by presenting the Revocation of Surrender Form, attached to this document, to the judge who is conducting this proceeding, or his or her successor.

b. By my signature to this part, I acknowledge receipt of a copy of the Revocation of Surrender form.

6. I FREELY AND VOLUNTARILY, WITHOUT DURESS OF ANY KIND, SURRENDER ALL OF

MY PARENTAL OR GUARDIANSHIP RIGHTS TO _______________

TO: (CHILD'S NAME)

a. Licensed Child-Placing Agency _______________ (Name of LCPA)

b. ___ Tennessee Department of Children's Services (Please check if applicable.)

FURTHER AFFIANT SAITH NOT.

This the ___ day of ______, 20 ___.

Signature: Biological ___, Legal ___ Mother __________________

Biological ___, Legal ___ Father __________________

Legal Guardian _____________________

Sworn to and subscribed before me this the ___ day of _______, 20 ___.

Please ____________________

Print:

___ Chancellor, ___ Circuit Judge, ___ or Juvenile

Court Judge

of ______________ County, Tennessee

Signature: ____________________

*See Note ___ Chancellor, ___ Circuit or ___ Juvenile Court

Below Judge

Before

Signing

NOTES TO THE COURT:

1. Please see T.C.A. 36-1-110 and 36-1-111(b), (c), (d), and (e) for capacity to execute and receive surrenders and requirements for validity.

2. A separate medical/social history form for the child and the child's parent(s) and biological relatives must be completed under oath prior to execution of the surrender. T. C. A. § 36-1-111(k).

3. When applicable, as noted above, all provisions of Section B. must be completed as directed prior to acceptance of the surrender and before entry of an Order of Full or Partial Guardianship. T.C.A. 36-1-111(k), (m) and (o). Section B.4. does not have to be completed by the Department of Children's Services. T.C.A. 36-1-111(n).

4. The surrender itself is not sufficient to vest custodial or guardianship authority with the Licensed Child-Placing Agency or the Department of Children's Services. T.C.A. 36-1-111(r)(2). Upon satisfactory completion of the above necessary requirements in Section B. and execution of the Pre-Surrender Form in Part I and Section A. of Part II by the parent or legal guardian, the Court shall enter an Order of Full or Partial Guardianship for the Licensed Child-Placing Agency or the Tennessee Department of Children's Services. T.C.A. 36-1-111(r)(6)(C). This should be done within thirty (30) days of the execution of the surrender. T.C.A. § 36-1-111(u).

NOTES TO THE CLERK:

1. Certified copies of Parts I and II must be given to the person(s) executing the surrender and to the Licensed Child Placing Agency or the county office of Tennessee Department of Children's Services. Costs of the copies may be taxed to the LCPA or the Department. Certify these copies on the page following Part II. T.C.A § 36-1-111(p).

2. The originals of Parts I and II shall be entered on a special docket for Surrenders and shall be styled "In Re: _______________" (Child's Name) and shall be permanently filed by the court in a separate file for that purpose, and shall be confidential and shall not be inspected by anyone else without the written approval of the court. T. C. A. 36-1-111(p).

3. Within five (5) days of the execution of the surrender, a certified copy of Parts I, II and III shall be sent, without cost, to: Adoptions Services, Tennessee Department of Children's Services, 436 6th Avenue North, Nashville, TN 37243-1290. T.C.A. 36-1-111(p)(1), (2) and (4). Please provide certifications for these on the pages following Parts II and III.

PART II

B. ACCEPTANCE OF SURRENDER BY LICENSED CHILD-PLACING AGENCY OR TENNESSEE DEPARTMENT OF CHILDREN'S SERVICES

STATE OF ____________ )

COUNTY OF ___________ )

Being duly sworn according to law, affiant would state:

1. I, ____________, an authorized representative of:

a. Licensed Child-Placing Agency _______________; or the

b. _________ County Tennessee Department of Children's Services accept the surrender of:

c. Name of Child _______________. DATE: _________

Please Print: __________________

Name and Title of Authorized Representative

Signature: __________________

Signature of Authorized Representative

SUBSECTIONS 2a.-2d. MUST BE MARKED TO DESIGNATE THE APPLICABLE SITUATION. ONE OF THESE SUBSECTIONS MUST EXIST BEFORE THE SURRENDER CAN BE RECEIVED BY THE COURT:

2. I ____________ certify on behalf of:

Licensed Child-Placing Agency ________________ (Name of Agency); or the ___ Tennessee Department of Children's Services:

a. ___ That my agency has physical custody of this child; or

b. ___ That my agency has received the affidavit required by § 36-1-111 (d)(6) concerning the right to receive custody from the surrendering parent or guardian within five (5) days of the date of this surrender. The affidavit of the custodial parent or guardian to that effect has been presented to the court at this time; or

c. ___ My agency has the right to receive physical custody of the child upon his or her release from a hospital or health care facility, and the affidavit of the custodial parent or guardian to this effect required by § 36-1-111 (d)(6) has been presented to the court at this time; or

d. ___ That another person or agency has physical custody of the child. The affidavit of that person or agency required by § 36-1-111 (d)(6) which indicates their waiver of the right to custody of the child upon entry of an order of guardianship pursuant to § 36-1-136(r) has been presented to this court at this time.

SUBSECTIONS 3. AND 4. MUST BE ANSWERED "YES" OR MUST BE MARKED "NOT APPLICABLE" BEFORE THE SURRENDER IS COMPLETED BY THE COURT.

3. Yes [ ] No [ ] That if the Indian Child Welfare Act, 25 U.S.C. § 1901 et seq., applies because of the child's Native American heritage, there has been compliance with the Act. [ ] Not Applicable

4. Yes [ ] No [ ] (Licensed Child-Placing Agency Only) I have presented to the court a copy of the Interstate Compact on the Placement of Child Form 100A for a child brought into Tennessee for adoption or foster care. If the ICPC Form 100A is not available, explain why this is not required.

_______________________________________

[ ] Not Applicable

FURTHER AFFIANT SAITH NOT.

This ____ day of _____, 20 ___.

Signature: ____________________

Authorized Representative of Licensed Child-Placing Agency

or the Tennessee Department of Children's Services

Sworn to and subscribed before me this the ____ day of ______, 20 ___.

Please Print: ____________________

___ Chancellor, ___ Circuit or ___ Juvenile Court Judge

of ____________ County, Tennessee

Signature: ____________________

___ Chancellor, ___ Circuit or ___ Juvenile Court Judge

CERTIFICATION

I, ________________, Clerk of the ____________ Court for _______________ County, Tennessee hereby certify the foregoing copies of Parts I and II of the Surrender Forms to be true and accurate copies of the documents filed with the court.

________________

Clerk of the __________ Court of

__________ County, Tennessee

(Seal)

PART III

CONTACT VETO REGISTRATION T.C.A. § 36-1-111(k)(3)

STATE OF ____________ )

COUNTY OF ___________ )

Being duly sworn according to law affiant would state:

1. I am:

a. Mother: ______________________, or

b. Father: ____________________, or

c. Legal Guardian: __________________ of:

2. a. Child's Name: ___________________

b. Child's Date of Birth: _______________

c. Child's Place of Birth: _______________

d. Child's Sex: __________________

e. Child's Race: __________________

3. a. I understand that contact with me may be requested by the child I am surrendering (adopted person) and by certain other classes of eligible persons who, as may be permitted by law, may have access to the sealed records, sealed adoption records or post adoption records and those records in any other information. Those eligible persons currently include the adopted person twenty-one (21) years of age or older or their legal representative, the adopted person's birth or adopted parents or step-parents, the birth or adopted siblings or lineal descendants twenty-one years of age or older of the adopted person, or their legal representatives. [T.C.A. § 36-1-127(c)]. The class of eligible persons may be revised periodically by changes to the law.

b. I understand that no contact, whether by personal contact, correspondence or otherwise shall be made in any manner whatsoever by those requesting persons or any agent or other person acting in concert with those requesting persons, with any person eligible to file a contact veto except as permitted by law. The sealed adoption record or post-adoption record requested by eligible persons shall be made available to the requesting party only after completion by the requesting party of a sworn statement agreeing that he or she shall not contact or attempt to contact, in any manner, by themselves or in concert with any other persons or entities, any of the persons eligible to file a contact veto until the Department has completed a search of the Contact Veto Registry to determine the willingness of the person sought to have contact with the requesting party. [T.C.A. §§ 36-1-127(f); 36-1-130 and 36-1-131]. The person making contact in violation of the law shall be guilty of a Class B misdemeanor [T.C.A. § 36-1-132]. I also understand that should I be contacted after filing a contact veto, I shall have a cause of action in the Circuit or Chancery Court for injunctive relief and damages, including both compensatory and punitive damages, and attorneys fees against any person who has contacted, attempted to contact, or caused me to be contacted [T.C.A. § 36-1-132].

4. I understand that contact with me by an eligible person is governed by filing my intentions with the Contact Veto Registry.

5. By filing with the execution of this surrender, I understand there is no fee for filing with the Contact Veto Registry. However, should I choose not to file a contact veto at this time, but wish to do so later, I understand I may do so, but will be required to pay the necessary fees [T.C.A. § 36-1- 129(b)]. I understand that should there be a request for contact with me and I have vetoed contact with any eligible person, I will be contacted and informed by the Department of Children's Services to determine my desires for contact at that time and will be given the opportunity to vary or modify my request. [T.C.A. § 36-1-130(b)(1)].

6. I understand that I may vary this contact veto by indicating my desires for contact, if any, with the eligible persons and the means of contact I wish to have with particular eligible persons. [T.C.A. § 36-1-111(k)(3)(B); § 36-1-127-36-1-131]. In doing so, I understand I must write to the address below and request the necessary forms to complete and file with the Contact Veto Registry:

CONTACT VETO REGISTRY

POST ADOPTION SERVICES

TENNESSEE DEPARTMENT OF CHILDREN'S SERVICES

436 6TH AVENUE NORTH

NASHVILLE, TENNESSEE 37243-1290

7. a. PLEASE COMPLETE THE FOLLOWING SO THAT YOU MAY BE LOCATED IN THE FUTURE BY THE DEPARTMENT CONCERNING YOUR INTENTIONS REGARDING CONTACT:

THIS INFORMATION MUST BE UPDATED WITH THE DEPARTMENT TO ENSURE THAT FUTURE CONTACT CAN BE MADE.

________________, ________________,

Name (Including Birth & Married Names) (Street/Rural Route/P. O. Box)

_______________, _________, _____,

(Town/City) (State) (Zip Code)

____________, ____________.

(Home Telephone No.) (Work Telephone No.)

b. Is this address an address the department may use to write to you concerning your wishes regarding contact.

Yes [ ] No [ ] If no, please share address to be used:

________________, _________, _____

(Street/Rural Route/P. O. Box) (Town/City) (State)

_____, _________, ________________.

(Zip Code) (Work Telephone) (Home Telephone)

c. Is this address an address a person requesting contact may use to write to you?

Yes [ ] No [ ]. If no, please share the address to be used:

________________, _________, _____

(Street/Rural Route/P. O. Box) (Town/City) (State)

_____, _________, ________________.

(Zip Code) (Work Telephone) (Home Telephone)

d. Are the telephone numbers the numbers the department may use to contact you? YES [ ] NO [ ].

If no, may the listed telephone numbers be shared with eligible persons requesting contact? YES [ ] NO [ ]. If no, please list telephone number(s), if any, that might be shared and used to contact you.

____________, ____________.

(Work Telephone No.) (Home Telephone No.)

8. a. I wish to veto contact with the adopted person and all other classes of eligible persons, who may, as may be permitted by law, to have access to the sealed records, sealed adoption records or post adoption record to have contact with me. [ ]

b. The filing of a contact veto by you makes the contact veto automatically applicable to your siblings, lineal descendants, lineal ancestors, and the spouses of those persons so that they cannot be contacted by a person eligible to have the records opened. You may, however, exclude persons in those classes from this automatic coverage so that they will have to register a contact veto themselves or, upon location by the department, pursuant to a search request, they will have to register a contact veto at the time. [T.C.A. § 36-1-130(a)(6)]. Please indicate whether you wish to exclude any of these persons.

c. I wish to exclude from the automatic contact veto the following:

(1) My siblings: Yes [ ] No [ ]

(2) My lineal descendants: Yes [ ] No [ ]

(3) My lineal ancestors: Yes [ ] No [ ]

(4) The spouses of:

(a) siblings Yes [ ] No [ ]

(b) lineal descendants Yes [ ] No [ ]

Please complete the following for any known individuals:

Name Relationship To Surrendering Address Street. RR, P. O. Box, Town,

Person State, Zip

-------------------------------------------------------------------------------

d. I wish to veto contact with: [T.C.A. § 36-1-128(c)]

(1) Any future siblings of the adopted person. Yes [ ] No [ ]

(2) A current spouse Yes [ ] No [ ] Name of current spouse ________________

(3) Future spouse of mine Yes [ ] No [ ]

(4) Any of my lineal descendants Yes [ ] No [ ]

Please complete the following for any known individuals:

Name Relationship To Surrendering Address Street. RR, P. O. Box, Town,

Person State, Zip

-------------------------------------------------------------------------------

9. a. I give consent for the child I am surrendering (adopted person) and ALL other classes of eligible persons who, as may be permitted by law, to have access to the sealed records, sealed adoption records or post adoption record to have contact with me. [ ]

b. I wish to limit consent to certain persons and only give consent for contact with the following classes of people:

(1) The adopted person Yes [ ] No [ ]

(2) The adopted person's adoptive parents Yes [ ] No [ ]

(3) The adopted person's adoptive siblings Yes [ ] No [ ]

(4) The adopted person's lineal descendants Yes [ ] No [ ]

(5) The legal representatives of any of these persons Yes [ ] No [ ]

c. If contact is limited to the legal representative of certain classes of persons, please describe:

_______________________________________

10. I wish the following types of contact by those persons requesting contact with me: (Please check all that apply and indicate any limitations or qualifications to these methods of contact)

Telephone [ ] ________________________

Letters [ ] _________________________

Personal contact, unannounced [ ] __________________

Personal contact, prearranged with me [ ], either via phone [ ] or correspondence [ ]

Personal contact through another person. Please give name, relationship to you, if any, and information to be released regarding how to contact: ________

_____________________________________________________________________________

__________________________________________

11. Other information I wish to have released about me to any eligible persons (please identify to whom and the contents of the information to be provided)

_____________________________________________________________________________

__________________________________________

12. Should you wish no contact with any other eligible persons but wish to share a statement of your feelings, or circumstances which impact your decision, please share that information here:

_____________________________________________________________________________

__________________________________________

13. I hereby request that this information be filed with the Contact Veto Registry at the Post Adoption Services Unit of the Department of Children's Services

FURTHER, AFFIANT SAITH NOT.

This the ___ day of ______, 20 ___.

Signature: Biological ___ Legal ___ Mother ____________

Biological ___ Legal ___ Father ____________

Legal Guardian __________________

Sworn to and subscribed to before me this ____ day of ______, 20 ___.

Please Print: _______________

___ Chancellor, ___ Circuit Judge, ___ Juvenile Court Judge of

_________ County, Tennessee

Signature: _______________

Chancellor, Circuit Judge, Juvenile Court Judge

CERTIFICATION

I, ____________, Clerk of the _________ Court of __________ County, Tennessee, certify the foregoing copy of Part III of the Surrender Forms to be a true and accurate copy of the document executed before this Court.

________________

Clerk of the __________ Court of

__________ County, Tennessee

(Seal)

PART IV

REVOCATION OF SURRENDER BY A PARENT OR GUARDIAN

STATE OF TENNESSEE

COUNTY OF __________

Being duly sworn according to law affiant would state:

1. I am:

a. Mother: ______________________, or

b. Father: ____________________, or

c. Legal Guardian: __________________, of:

2. a. Child's Name: ___________________

b. Child's Date of Birth: _______________

c. Child's Place of Birth: _______________

d. Child's Sex: __________________

e. Child's Race: __________________

3. On __________ (Date), I executed a surrender of my parental or guardianship rights to the child named in #2 to:

a. Prospective Adoptive Parent(s) __________________

b. Licensed Child-Placing Agency __________________

c. Tennessee Department of Children's Services _______________.

4. The surrender was executed before: ______________________

(Name of Judge and Name of Court)

5. I hereby revoke and void the surrender of the above-named child.

FURTHER AFFIANT SAITH NOT.

This the ___ day of _____, 20 ___.

Signature: Biological ___ Legal ___ Mother ____________

Biological ___ Legal ___ Father ____________

Legal Guardian: __________________

Sworn to and subscribed before me this ___ day of ______, 20 ___.

This Revocation of Surrender was received by me on the ___ day of ______, 20 ___.

Please Print: _______________

___ Chancellor, ___ Circuit Judge, or ___ Juvenile Court

Judge

of _________ County, Tennessee

Signature (See _______________

notes below):

___ Chancellor, ___ Circuit Judge, or ___ Juvenile Court

Judge

NOTES TO COURT, OR OTHER PERSON AUTHORIZED TO RECEIVE A REVOCATION, AND TO THE CLERK:

1. If the judge or other person who received the surrender is unavailable or absent, the successor or substitute to that judge or person may accept the revocation, or in the absence of the judge or his or her successor, another judge with jurisdiction to receive a surrender (in another state or territory this would be the chancellor, judge, or clerk of a court of record) may accept the revocation. In the event the surrender was taken in another state or country, or before the warden of a state or federal penitentiary and there is no authorized successor to the person who received the surrender or that person is unavailable, the revocation may be taken by a court in Tennessee which is qualified to receive a surrender or by a court in another state, territory, or country with domestic relations jurisdiction to accept the revocation. T.C.A. § 36-1-112(a)(1).

2. The surrender must be revoked within ten (10) days including Saturdays, Sundays and legal holidays following the original execution of the surrender. T.C.A. § 36-1-112(a)(1). The revocation period will begin on the day following the signing of the surrender and will expire on the tenth (10th) day. If the tenth (10th) falls on a Saturday, Sunday or legal holiday, the last day for revocation will be the next day which is not a Saturday, Sunday or legal holiday.

3. The court or person receiving the revocation shall maintain the originals in the office of the clerk or the person receiving the surrender together with the original of the surrender or the adoption petition containing the parental consent, if available, and shall personally give, or by certified mail, return receipt requested, send certified copies of the revocation to the child's parent(s) or legal guardian(s), and to the prospective adoptive parents or the local office of the Tennessee Department of Children's Services or the licensed child-placing agency to whom the child was surrendered. See, T.C.A. § 36-1-112(c)(1).

4. a. A certified copy of the revocation shall be attached to a certified copy of the surrender or the petition for adoption containing the parental consent, and the clerk shall send these, within three (3) days by certified mail, return receipt requested to:

Tennessee Department of Children's Services

Central Office

Adoption Services

436 6th Avenue North

Nashville, TN 37243-1290

See, T.C.A. § 36-1-112(c)(2).

b. Please provide the certification on the page following this Revocation form.

5. If the revocation must be executed before a court or person before whom the surrender was not executed or in which the adoption petition was not filed, the original of the revocation shall be sent within three (3) days to the court or person before whom the surrender was executed or where the adoption petition was filed and that court or person shall be responsible for sending the forms to the Tennessee Department of Children's Services Central Office and to the persons or agencies in #3 entitled to copies of the revocation. See, T.C.A. § 36-112(c)(2)(B).

CERTIFICATION

I, ____________, Clerk of the _________ Court of __________ County, Tennessee, certify the foregoing copy of the Revocation of Surrender to be a true and accurate copy of the Revocation of Surrender executed before this Court.

________________

Clerk of the __________ Court of

__________ County, Tennessee

(Seal)

Authority: T.C.A. §§ 4-5-201, et seq., 36-1-111, 36-1-112, 36-1- 125(a), 36-1-141, Public Chapter 532 (1995), and Executive Order #6, January 12, 1996. Administrative History: Original rule filed September 7, 2001; effective November 21, 2001.