CONSENT TO ADOPTION BY MINOR WHO IS FOURTEEN (14) YEARS OF AGE OR OLDER TENNESSEE CODE ANNOTATED, §36-1-117(I) STATE OF TENNESSEE COUNTY OF _______________ Being duly sworn according to law, affiant would state: 1. I am _____________________________________________ , (Use the name of minor child prior to any name change requested in the Petition, fourteen (14) years of age or older, born _______________ (Date of Birth). 2. I understand that _________________________________________ , (name of prospective adoptive mother), and ___________________________________________ , (name of the prospective adoptive father), have filed a Petition to adopt me. 3. I understand that if the Court enters an order of adoption based upon the Petition, that I will become the legal child of ______________________________________________ , (name of prospective adoptive mother, and ______________________________________________ , (name of prospective adoptive father, and that they will become my parent(s) for all purposes, just the same as if I had originally been born to them (him/her). 4. I understand that, while I remain under eighteen (18) years of age, my adoptive parent(s) will have the right to determine if I should contact or visit with anyone in my birth family. 5. I understand that I will have the right to inherit property from my adoptive parent(s), and their (his/her) descendants will have the right to inherit property from me or my descendants, but only for property I acquire after the adoption order is entered. After the order of adoption is entered, I will not inherit property from my birth family, nor will they inherit property from me after the order of adoption is entered. I may inherit from or through a parent whose rights were not terminated before his or her death. 6. No one has pressured me to agree to this adoption, and I believe that my adoption by ____________________________________________________ , (name of prospective adoptive mother, and ________________________________________________________ , (name of prospective adoptive father), is in my best interests. I wish for the adoption to take place. 7. Do you freely and voluntarily, without pressure from anyone, consent to this adoption? Yes No This the _____ day of _________________ , _______ FURTHER AFFIANT SAITH NOT Please print: Name of Minor Child Signature: Sworn to and subscribed before me this _____ day of _________________ , _______ Please print: Chancellor of the Chancery Court for Shelby County Tennessee Signature: American LegalNet, Inc. www.USCourtForms.com