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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 |