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 I do not have my own lawyer, I understand that I am free to go obtain my own lawyer and this surrender process will stop until I have done so, or I may continue without my own lawyer at this time. The judge or other officiant has also advised me that I have the right to a lawyer.
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:
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. ______________ ______________ ______________
Yes [ ] No [ ]
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: ______________ ______________ ______________
For a custodian, other than the surrendering party, please list the custodians:
Custodian(s) ______________
Street ______________
City ______________, State ____________________, Zip ______________
Telephone Number: Home: ____________________Work: ____________________
Do you understand that all these things are available? Yes [ ] No [ ]
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:
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:
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
DENIAL OF PATERNITY AND NOTICE BY A LEGAL FATHER
STATE OF ____________________
COUNTY OF ____________________
Pursuant to Tennessee Code Annotated § 36-1-111(t), 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.
T.C.A. § 36-1-111