TENNESSEE SURRENDER FORM
I, (full name of surrendering party) , born (surrendering party's date of birth) , sign this surrender to end my parental rights and responsibilities to (full name of child) , born (child's date of birth) in (location of child's birth) . I am this child's (circle one) mother / father / possible father / guardian.
I surrender my parental rights to and request that this Court give guardianship to (a person/family with a current, approved home study, or a licensed child-placing agency) .
I know I only have three (3) days to change my mind and revoke this decision after I sign this form. This decision may not be changed if I do not revoke this surrender on or before (three days after today, calculated under Tennessee Rule of Civil Procedure 6.01). To revoke, I must sign a revocation form before the Judge or officiant with me now or his or her successor.
I have completed the Surrendering Party Pre-Surrender Information Form. I have provided true and complete answers to all the questions on that form to the best of my knowledge.
I know that I should only sign this form if I want my parental rights terminated. If I want to talk to my own lawyer before I sign this form, I should tell the Judge or other officiant now and this surrender process will stop. I can talk to my lawyer and then decide if I still want to end my parental rights.
If anyone is putting pressure on me to sign this surrender, or trying to make me sign against my will, or has promised me something I value in order to make me want to sign this surrender, I understand that I should tell the Judge or officiant about that before I sign this form. The Judge or officiant will not allow me to be forced to sign this surrender.
No one is pressuring, threatening, or paying me to get me to sign this form. I believe voluntary termination of my parental rights is in the best interest of my child.
By signing below I voluntarily terminate my parental rights and surrender my child to the person(s) or agency listed above.
This day of , 20 .
Surrendering Party's Signature
Judge or Officiant Attestation
I interviewed the surrendering party and witnessed execution of the foregoing surrender as required by T.C.A. §36-1-111. The surrendering party understands that he/she is surrendering parental rights to this child. There is no reason to believe that this is not a voluntary act.
The Surrendering Party's Pre-Surrender Information Form, the surrendering party's Social and Medical History Form, and if the surrender is to an individual, or individuals, as opposed to an agency, the individual's, or individuals', court report based upon a current and approved home study are attached to this form. The Pre-Surrender Information Form and Social and Medical History Form are properly verified by a notary or I reviewed the information with the surrendering party and he/she has attested before me to the correctness of those forms.
This day of , 20 .
Judge or Officiant's Signature
Name and Title:
Court or Employing Institution and Location:
ACCEPTANCE BY AGENCY or PROSPECTIVE ADOPTIVE PARENT(S)
I/We and individually or I, , on behalf of the licensed child-placing agency, , hereby accept the surrender of (child) from (surrendering party) and plan to adopt the surrendered child or for an agency, expect and intend to place this child for adoption with an appropriate family. I/We or the undersigned agency have physical custody of this child or will have physical custody upon discharge of this child from a healthcare facility. I/We or the undersigned agency agree(s) to assume responsibility for obtaining guardianship of the surrendered child through a court order within thirty (30) days of the date of the surrender. I/We or the undersigned agency agree(s), to be responsible for the care, custody, financial support, medical care, education, moral, and spiritual training of this child, pending an adoption.
I/We have completed the Accepting Party's Pre-Acceptance Information Form. The information provided in that form is true to the best of my/our knowledge.
This day of , 20 .
Signature of Prospective Adoptive Parent
Signature of Prospective Adoptive Parent
Signature of Agency Representative and Title
Judge or Officiant Attestation
I interviewed the accepting parties and witnessed execution of the foregoing acceptance.
The Accepting Party's Pre-Acceptance Information Form and any accepting individual's/individuals' court report based upon a current and approved home study are attached to this form. The Accepting Party's Pre-Acceptance Information Form is properly verified by a notary or I reviewed the information with the accepting parties and they have attested before me to the correctness of the form.
This day of , 20 .
Judge or Officiant's Signature
Name and Title:
Court or Employing Institution and Location:
SURRENDERING PARTY'S PRE-SURRENDER INFORMATION FORM
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 [ ] in wedlock but the mother's husband is not the child's biological father [ ].
4. State the names and relationships of any other legal parents, putative fathers, and legal guardians for this child:
a.
b.
5. If the above named parties' whereabouts are unknown, please describe why that is the case:
6. Is the child or surrendering parent or another legal parent of the child a member of a federally recognized American Indian or Alaskan Native tribe?
If “yes,” please provide the name and address of the tribe, all available information regarding the tribal membership, including a membership number if there is one, or the basis for the belief that one may be a tribal member. If there is a tribal membership card or tribal enrollment document please provide a copy by attaching it to this form.
7.
a. Will this child be sent out of Tennessee to another state for adoption?
Yes [ ] No [ ]
b. If yes, name of state:
8. Have you been paid, received, or promised any money or other remuneration or 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 #9.
If yes, please list the amount paid, to whom the payment was made, who made the payment, when was the payment made, and for what purpose the payment was made:
9. Does the child own any real or personal property? Yes [ ] No [ ] If yes, please describe property, its value, and any relevant circumstances:
10.
a. I currently have (___) legal, (___) physical, or (___) legal and physical custody of the child.
b. If someone else has legal or physical custody of the child, please identify the person or agency that holds custody of the child and whether they have legal custody, physical custody, or both.
For a custodian, other than the surrendering party, please list the custodians:
Custodian(s)
Street
City , State , Zip
Telephone Number: Home: Work:
11.
a. There may be state assistance-money, classes, health insurance, food aid and such, available to help you if you parent the child yourself.
b. There is counseling available if you want to talk to a counselor about your choice before you sign a surrender form.
c. You can talk to a lawyer who only represents you, if you want to, before you sign a surrender form.
Do you understand that all these things are available? Yes [ ] No [ ]
12. Contact Veto.
I understand that information about who I am, where I live, my social and medical history and other similar information will be available to the adopted person when he/she is 21 years old or older if the adopted person asks for the information. Identifying information about me will not be released if I am the victim of rape or incest and that fact is known to DCS and I have not consented to release of the information. Even if the adopted person obtains information about me, I understand that I may direct that the adopted person not be allowed to contact me by registering a “contact veto” on this form or separately with the Tennessee Department of Children's Services at:
Contact Veto Registry Post Adoption Unit Tennessee Department of Children's Services 315 Deaderick Street UBS Tower, 9th Floor Nashville, TN 37243
I may also change my previously expressed direction regarding contact at the same address. If I am contacted in violation of a contact veto, the adopted person will be guilty of a Class B misdemeanor and I can sue them for injunctive relief and compensatory and punitive damages and attorney's fees.
a. Do you want to register a contact veto in order to prevent the adopted person from contacting you in the future? Yes [ ] No [ ].
b. If identifying information about you is going to be released to the adopted person do you want to be notified before the information is released? Yes [ ] No [ ].
c. Please supply a permanent address and telephone number for the Department to use to consult with you regarding release of information about you to the adopted person:
d. Please describe any other directions regarding future contact and or any information you want passed on to the adopted person:
FURTHER, AFFIANT SAITH NOT.
This 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 .
Notary Public
My commission expires:
(A notary is necessary if information on this form is not reviewed by and acknowledged before a Judge or officiant.)
ACCEPTING PARTY'S PRE-ACCEPTANCE INFORMATION FORM
STATE OF
COUNTY OF
Being duly sworn affiants would state:
1.
a. I am , Prospective Adoptive Parent.
b. Prospective Adoptive Parent's Date of Birth
c. Prospective Adoptive Parent's Place of Birth
d. Prospective Adoptive Parent's Marital Status
2.
a. I am , Prospective Adoptive Parent.
b. Prospective Adoptive Parent's Date of Birth
c. Prospective Adoptive Parent's Place of Birth
d. Prospective Adoptive Parent's Marital Status Or
3. I am , representative of a licensed child placing agency with offices at:
4. The following costs have been paid or promised by (me/us) for activities involving the placement of this child. Please include, amount paid or promised, to whom, by whom, date paid and type of service or cost:
5.
a. ____ I/We have physical custody of this child; or
b. ____ I/We will receive physical custody of the child from the parent or legal guardian within five (5) days of this surrender; or
c. ____ I/We have the right to receive physical custody of the child upon his or her release from a hospital or health care facility; or
d. _____ Another person or agency currently has physical control of the child. I/We have presented to the court an affidavit of the person or agency required by T.C.A §36-1-111(d)(6) which indicates their waiver of right to custody of the child upon entry of a guardianship order pursuant to T.C.A. § 36-l-136(r).
6. Yes [ ] No [ ]. I/We have presented to the court a currently effective or updated home study or preliminary home study of my/our home conducted by a licensed child-placing agency, a licensed clinical social worker, or the Tennessee Department of Children's Services as required by Tennessee law. (Not applicable for agency placements)
7.
a. If the child is to be removed from Tennessee for adoption in another state, will there be compliance with the Interstate Compact on the Placement of Children. Yes [ ] No [ ] Not Applicable [ ].
b. If yes, who will be responsible for preparing and submitting the ICPC package?
FURTHER, AFFIANT SAITH NOT.
This day of , 20 .
Signature of Prospective Adoptive Parent
Signature of Prospective Adoptive Parent
OR
Signature of Representative of Agency
Name of Agency
Sworn to and subscribed before me this the day of , 20 .
Notary Public
My commission expires:
(A notary is necessary if information on this form is not reviewed by and acknowledged before a Judge or officiant.)
REVOCATION OF SURRENDER BY A PARENT OR GUARDIAN
STATE OF
COUNTY OF
Being duly sworn affiants would state:
1. I am:
a. Mother:
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 or Officiant)
5. I hereby revoke the surrender of the above-named child.
FURTHER, AFFIANT SAITH NOT.
This 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:
Signature:
Judge or Officiant
WAIVER OF INTEREST AND NOTICE STATE OF ) COUNTY OF ) Pursuant to Tennessee Code Annotated, §36-1-111(w) , and first being duly sworn according to law, affiant would state the following: My name is . I understand that I have been named by , the mother of a child [to be born], or a [child who was born in (City) (State) on the day of , 19 (or 20 )], as the father or possible father of that child. I further understand that the mother has placed or wishes to place this child for adoption or that the child is the subject of legal proceedings leading to the child's adoption or leading to a determination of the child's legal custody or guardianship. I am not necessarily admitting or saying that I am the father of this child, but if I am, I do not wish to provide care for this child, and I feel it would be in the child's best interest for this adoption to occur, or for other custody or guardianship proceedings to occur in the child's best interests. I hereby formally waive any right to notice of the legal proceedings: to adopt this child; to otherwise make this child available for adoption; or to award the child's legal custody or guardianship to other persons or agencies. I hereby formally waive any further parental rights to the child and execute this document to finally terminate my rights, if I have any rights, to this child, upon entry of a final order of adoption for this child. If the child is not yet born: [I have received and reviewed a copy of the statement of the child's mother in which the mother identifies me as the father of the child.] I consent to adoption of this child by any persons chosen by the child's mother or by any public or private agency, and consent to the establishment of any legal custody or guardianship arrangements for the child. I understand that by execution of this waiver, this child may be adopted by other persons or that other custody or guardianship proceedings regarding the child's status may occur and that I will have no rights, if I have any, to act as parent, to visit with, or otherwise be involved in this child's life, unless and until a legal relationship is established between me and the child. I further understand that I may not revoke this waiver at any time after I sign it. I further understand that if the child is not adopted, that legal proceedings can be brought to seek to establish me as the legal father, and I may become liable for financial support or financial obligations for this child or to the child's mother that are related to the child's support, arising after I sign this waiver, and beginning on the date an order is entered that establishes me as the child's father or beginning on the date I sign a voluntary acknowledgment of paternity of the child. I also understand that if the child is not adopted and paternity is later established by legal proceedings, or if I sign a voluntary acknowledgement of paternity, I could be liable for all or a portion of the actual medical and hospital expenses of the child's birth and all or a portion of the mother's prenatal and postnatal care up to thirty (30) days following the child's birth if the legal proceeding to establish me as the child's father is brought, or the voluntary acknowledgment of paternity of the child is signed, within two (2) years of the date I sign this waiver. FURTHER, AFFIANT SAITH NOT. DATED: THE DAY OF ,19 (20 ). Alleged Father (Please Print) Signature of Alleged Father Address Personally appeared before me the above-named who is known to me and who acknowledged that he executed the above Waiver of Interest and Notice as his own free and voluntary act. Notary Public My commission expires:
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DENIAL OF PATERNITY AND NOTICE BY A LEGAL FATHER
STATE OF
COUNTY OF
Pursuant to Tennessee Code Annotated §36-1-111(x), and first being duly sworn according to law, affiant would state the following:
My name is . I am personally acquainted with , the biological mother of , a child [to be born], or a [child who was born] in (City) (State) on the day of , 20 .
I am or I have been told that I am or may be the presumed and/or legal father of the above- named child.
I AM CERTAIN THAT I AM NOT THE BIOLOGICAL FATHER OF THIS CHILD.
I understand that the mother has placed or wishes to place this child for adoption, or that the child is the subject of legal proceedings leading to the child's adoption, or leading to a determination of the child's legal custody or guardianship. I do not want custody of this child. I either agree with an adoption plan or I do not wish to be involved in the decision.
I HEREBY WAIVE MY PARENTAL RIGHTS TO THIS CHILD, IF I HAVE ANY RIGHTS, AND I WANT MY PARENTAL RIGHTS, IF ANY, TO BE TERMINATED WITHOUT FURTHER ACTION BY, OR NOTICE TO, ME.
I formally waive my rights to notice of legal proceedings regarding the child including: adoption, custody, guardianship, and termination of other parents' rights and any other similar actions.
I understand that by my execution of this Denial of Paternity and Notice, along with the finalization of the child's adoption, I will lose any right I may have to act as parent, to visit with, or otherwise be involved in this child's life. I also relinquish any right to petition to have my legal and biological relationship to this child determined by a court.
I FURTHER UNDERSTAND THAT I MAY NOT REVOKE THIS DENIAL AT ANY TIME AFTER I SIGN IT.
I also understand that while this denial is not revocable, it is not effective to terminate my parental rights or responsibilities unless or until an adoption of the child is finalized. If the adoption is not finalized, I understand that I retain any rights that I otherwise had to rebut a presumption that I am the father of the child.
FURTHER AFFIANT SAITH NOT this DAY OF , 20 .
Legal Father (Please Print)
Signature of Legal Father
Address
City, State, Zip Code
Personally appeared before me the above-named , who is known to me and who acknowledged that he executed the above Denial of Paternity and Notice as his own free and voluntary act.
Notary Public My commission expires:
Name
Relationship to the child
Address
City, State, Zip
Name
Relationship to the child
Address
City, State, Zip
Telephone Number: Home: Work:
Other identifying information concerning the above identified other legal or biological parent/legal guardian.