1 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 the 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 and as required by T.C.A. 244 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: American LegalNet, Inc. www.FormsWorkFlow.com 2 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 and 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: American LegalNet, Inc. www.FormsWorkFlow.com 1 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 000 / in wedlock but the mother's husband is not the child's biological father 000. 4. State the names and relationships of any other legal parents, putative fathers, and legal guardians 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. 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/legal guardian. 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 000 No 000 b. If yes, name of state: American LegalNet, Inc. www.FormsWorkFlow.com 2 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 000 No 000 If no, go to #10. If yes, please list the amount paid, to whom the payment was made, whom 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 000 No 000. 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 000 No 000 12. Contact Veto. I understand that inform