1. (1) Sworn statement for access to adoption records, sealed records, sealed adoption records or post-adoption records of an adoption or attempted adoption of such person are maintained: ADOPTIONS FINALIZED ON AND AFTER MARCH 16, 1951 [READ CAREFULLY. COMPLETING THIS DOCUMENT INDICATES YOU UNDERSTAND THE LEGAL PENALTIES IF YOU VIOLATE THE TERMS OF THIS DOCUMENT] Sworn Statement for Access to Records Tennessee Code Annotated §§ 36-1-127 through 36-1-132 and § 36-1-141 STATE OF ____________________ COUNTY OF __________________

   1. 1. Being duly sworn according to law, I _______________________________________________, Full Name, Including Maiden & Married Name ___________________________________________________________________________________, (Rural Route/Street/P.O. Box) (City/Town) (State) (Zip) _______________ acknowledge and affirm that I understand the following terms governing my (Date of Birth) access to adoption records, sealed records, sealed adoption records, or post-adoption records maintained by the Department of Children’s Services or any other information source.
   2. 2. Having been determined eligible to receive access to the adoption records, sealed records, sealed adoption records and post adoption records of myself (__) or others (__) (check one), (if other, please identify relationship __________________________________), for whom adoption records, sealed records, sealed adoption records or post-adoption records of an adoption or attempted adoption are maintained:
   3. (a) I understand and avow that after I receive any of the records noted above through the Department of Children’s Services, I will not, either alone, or acting with others, attempt to establish contact or establish any contact personally or by correspondence, nor will I attempt to establish contact or establish any contact by any other means of contact with either the persons in the classes of persons described in Paragraph 6 below who may be discovered or otherwise identified in the records to which I am given access and who may have filed a contact veto or who may be eligible to register with the Contact Veto Registry or who may be protected by a current contact veto unless I receive consent from those persons through the Department of Children’s Services. I understand that if I wish to have contact with those persons after I receive access to these records, that the Department of Children’s Services must complete a search for such persons to determine if those persons have filed a contact veto or are protected by a contact veto prohibiting contact by me with them, or to determine if those persons wish to file a contact veto to prohibit or permit contact by me with them. (T.C.A. §§ 36-1-127, 36-1-130, and 36- 1-131)

   4. (b) I understand that an adopted person does not have to register a contact veto and may not be contacted by me or by any person(s) acting with or through me without that adopted person’s written consent to the Department and notice of the consent is given to me by the Department. I avow that I will not have contact with that adopted person without such consent. T.C.A. § 36-1-130(a)(6)(A)(vi).

      1. 3. I understand that, after obtaining information from the adoption records, sealed records, sealed adoption records, post adoption record or any other information source, should I or any other person use such information to cause injury to the person(s) whose name(s) are contained in the records and who are listed in the classes of persons in Paragraph 6 below, or who is an adopted person, whether or not consent has been given for contact, I may be guilty of committing a Class A misdemeanor, which is punishable by 11 months and 29 days in jail, and a fine of up to $2,500. The injured party shall have cause of action in the circuit or chancery court for injunctive relief and damages, including both compensatory and punitive damage against me or any person who uses the information in violation of these laws. [T.C.A. § 36-1-132(f); § 36-1-130, and § 36-1-127(f)]. ADOPTIONS FINALIZED ON AND AFTER MARCH 16, 1951
      2. 4. I understand that if I should contact, or attempt to contact, the persons who have filed a contact veto, persons to whom a contact veto applies, or if I should improperly contact an adopted person, or if I should cause those persons to be contacted through the use of a third party, then those persons shall have a cause of action in circuit or chancery court for injunctive relief and damages, including both compensatory and punitive damages against me or any person who has contacted, attempted to contact, or caused to be contacted. [T.C.A. § 36-1-127(f); § 36-1-130; and § 36-1-132(a)].
      3. 5. I understand that if I knowingly provide false information with regard to this statement or any information which I provide to the Department in regard to a search request, that such action constitutes a Class E felony punishable by 1–6 years in prison and a fine of up to $3,000. (T.C.A. § 36-1-139).
      4. 6. I understand that those persons eligible to register with the Contact Veto Registry are:
   5. (a) a parent of the adopted person;
   6. (b) a sibling of the adopted person;
   7. (c) a lineal descendant of the adopted person (i.e., children or grandchildren)
   8. (d) a lineal ancestor of the adopted person (i.e., a parent or grandparent);
   9. (e) a spouse of an adopted person; or

   10. (f) the legal representative of any person described above. NOTE: You may not have contact with any persons in the categories stated above whose identities are discovered in the records supplied to you without their consent and without notification by the Department as to the status of their refusal, or permission, to have contact if you do not state at this time the relationship of the person(s) with whom you wish to have contact so that the Department can make such a determination. If you are a person in the classes identified in parts (a)-(f) above, you may not contact an adopted person without that person’s written consent given by that adopted person to the Department and notification by the Department to you as to the status of that adopted person’s refusal, or permission, to have contact. [T.C.A. § 36-1-127(f); § 36-1-129] I understand that if the sealed records, sealed adoption records or the post adoption records do not establish the alleged parent’s relationship, the Contact Veto Registry must be cleared and I will be notified in writing by the Department of my rights to pursue contact with this person.

       1. 7. I wish to have contact with one or more of the persons eligible to register with the Contact Veto Registry. Yes  No  If yes, please identify by relationship and whether such person(s) are birth or adoptive relative(s). BIRTH OR ADOPTIVE RELATIONSHIP ____________________________________________________________________________________ ____________________________________________________________________________________
       2. 8. It is my understanding that the Department will determine if the person(s) I have listed have registered their preference for contact with the Contact Veto Registry or, if they are not registered on the Contact Veto Registry, the Department will conduct a diligent search for those persons I wish to have contact with to allow those persons the opportunity to file, withdraw or vary their desires for contact with the Contact Veto Registry. (T.C.A. § 36-1-130(a)(6)(A)(iii)(iv).
       3. 9. I understand that I will be advised by the Department of the response of the person(s) with whom contact is desired and, if permission for contact is given by the person(s) with whom I seek contact, the ADOPTIONS FINALIZED ON AND AFTER MARCH 16, 1951 Department will provide me with such information as may be available to establish contact. (T.C.A. § 36- 1-130(c)).
       4. 10. Should a contact veto have been filed by, or on behalf of, the person with whom contact is sought or if a contact veto is timely and effectively filed by the person with whom contact is sought after locating such person(s) as the result of a search, the Department will notify me in writing of such contact veto and no contact will be permitted. (T.C.A. § 36-1-131 (b)(2)(B)).
       5. 11. If the contact veto is required to be filed by a person for whom a search has been conducted and the veto has not been timely and effectively filed after location of the person(s) sought, the Department will notify me in writing and I will be permitted to attempt contact with the person(s) being sought only when directed by the Department. (T.C.A. § 36-1-131 (b)(2)(B)).
       6. 12. If the person with whom contact is sought cannot be located after a diligent search, I will be sent written notification by the Department. Then, and only then will I be under no further restrictions against contact with the person who has been sought. (T.C.A. § 36-1-131 (2)(B)(c)).
       7. 13. I understand that if I desire to have contact with any person that has not been identified in Paragraph 7 above at any point in the future I must again advise the Department of this request and the procedures described in this form and the rules of the Department regarding search and contact as stated above must be followed and an additional fee must be paid for this service. A new Sworn Statement may be filed at any point prior to the initiation of the search. Once the search has been initiated, the search must be completed in accordance with the Sworn Statement on file at the time the search was initiated. FURTHER, AFFIANT SAITH NOT. ________________________________________________ (Signature) Sworn to and subscribed before me this ______day of ________________, 19_______. _________________________________________ (Notary Public) My commission expires ____________________________________. ADOPTIONS FINALIZED ON AND AFTER MARCH 16, 1951

2. (2) Contact Veto Registry Application - Birth Relative: TENNESSEE DEPARTMENT OF CHILDREN’S SERVICES CONTACT VETO REGISTRY INTRODUCTION I understand that contact with me may be requested by certain classes of eligible persons who, as may be permitted by law, may have access to the sealed records, adoption records, sealed adoption records or post adoption records and those records in any other information source. An adopted person twenty-one (21) years of age or older, or his or her legal representative, is eligible to request access to these records. With the written permission by the adopted person to the Department of Children’s Services, the adopted person’s birth or adopted parents or step-parents, the birth or adopted siblings of the adopted person, lineal ancestors or lineal descendants twenty-one (21) years of age or older, of the adopted person or their legal representative may also obtain access to those records. The class of eligible persons may be revised periodically by changes to the law. 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 adoption record, sealed record, 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. [I understand that no contact may be made through any information contained in the records which I receive. (T.C.A. §§ 36-1-127(f), 36-1-130 and 36-1-131)] 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]. Any person who, after obtaining information from the records, uses such information to cause injury to the person whose name was obtained under this part, commits a Class A misdemeanor [T.C.A. § 36-1- 132]. Further, any person who has been injured pursuant to this subsection shall have a cause of action in the Circuit or Chancery Court for injunctive relief and damages, including both compensatory and punitive damages, against any person who uses the information in violation of this subsection. I understand that contact with me by an eligible person is governed by filing my intentions with the Contact Veto Registry. I understand there is a fee for filing with the Contact Veto Registry. 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. [If, however, I cannot be located or do not submit a modification or withdrawal to the contact veto I have previously filed, I understand that my contact veto remains in effect.[T.C.A. § 36-1-130(b)(1)]. ADOPTIONS FINALIZED ON AND AFTER MARCH 16, 1951 I understand that I may vary this contact veto by indicating my desires for contact, if any, with the eligible persons and the means of contact I wish to have with particular eligible persons. [T.C.A. § 36-1- 111(k)(3)(b); § 36-1-127-36-1-131]. In doing so, I understand I must write to the address below and request the necessary forms to complete and file with the Contact Veto Registry and pay any necessary fees: CONTACT VETO REGISTRY POST ADOPTION SERVICES TENNESSEE DEPARTMENT OF CHILDREN’S SERVICES 8TH FLOOR 436 6TH AVENUE NORTH NASHVILLE, TENNESSEE 37243-1290 ADOPTIONS FINALIZED ON AND AFTER MARCH 16, 1951 CONTACT VETO REGISTRY APPLICATION BIRTH RELATIVE SECTION 1: INFORMATION ABOUT YOURSELF (Everyone must complete this section) CHECK APPROPRIATE BLANK: Initial Filing _______ Varying Previous Filing ______ PLEASE COMPLETE THE FOLLOWING SO THAT YOU MAY BE LOCATED IN THE FUTURE BY THE DEPARTMENT CONCERNING YOUR INTENTIONS REGARDING CONTACT: SECTION 2: DETAILS OF BIRTH RELATIVE Your Present Relationship To Last Name Adopted Person Maiden Name All Previous Last Names First & Middle Name Your Date of Birth / / Place of Birth: County __________ City ______ State ______ Mailing Address Zip Code Telephone No. Home Business _____________________________ ____________________________ Area Code Number Area Code Number The current address and telephone numbers are needed to enable the Department to inform you if any eligible person makes a request for contact. The address does not have to be your residential address (a Post Office Box is sufficient). If you do not have a telephone, please note. ADOPTIONS FINALIZED ON AND AFTER MARCH 16, 1951 SECTION 3: INFORMATION PERTAINING TO RELATIVE PLACED FOR ADOPTION Last Name (Before Adoption) First & Middle Names Sex (F__M__) Date of Birth / / Place of Birth: County _____________ City _____________ State ____ Full Name of Birth Father Full Name of Birth Mother Type of Adoptive Department: ( ) Private/Independent: ( ) Placement Licensed Child-placing Agency: ( ) ____________________________________ Name of Agency Please check one. This information will assist the Department to locate the adoption records, but is not essential. SECTION 4: CONTACT VETO

   1. a. I wish to veto contact with all 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 who may wish to have contact with me. YES  NO  (Item “c” must be completed.)
   2. b. The filing of a Contact Veto Registry Application by you makes the contact veto automatically applicable to your siblings, lineal descendants, lineal ancestors, and the spouses of those persons so that they cannot be contacted by a person eligible to have the records opened. You may, however, exclude persons in those classes from this automatic coverage so that they will have to register a contact veto themselves or, upon location by the Department, pursuant to a search request, they will have to register a contact veto at that time. [T.C.A. § 36-1-130(A)(6)]. Please indicate whether you wish to exclude any of these persons.
   3. c. I wish to exclude from the automatic contact veto the following:
3. (1) My siblings or future siblings: YES  NO  (brothers and sisters)
4. (2) My lineal descendants: YES  NO  (children and grandchildren)
5. (3) My lineal ancestors: YES  NO  (parents and grandparents)

6. (4) The spouses of my:

   1. (a) myself YES  NO  ADOPTIONS FINALIZED ON AND AFTER MARCH 16, 1951
   2. (b) siblings YES  NO 
   3. (c) lineal descendants YES  NO 

   4. (d) lineal ancestors YES  NO  If you have marked “YES” in any part of item “c.”, please complete the following for any known individuals: Relationship to Person Address Name Completing the Form Street, RR, PO Box, Town, State, Zip SHOULD YOU WISH NO CONTACT WITH ANY OTHER ELIGIBLE PERSONS BUT WISH TO SHARE A STATEMENT OF YOUR FEELINGS, OR CIRCUMSTANCES WHICH IMPACT YOUR DECISION, PLEASE SHARE THAT INFORMATION HERE: _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ SECTION 5: CONTACT CONSENT (Complete only if you wish to consent to contact)

      1. a. I give consent for ALL other classes of eligible persons who, as may be permitted by law, to have access to the adoption records, sealed records, sealed adoption records or post adoption record to have contact with me. YES  NO 
      2. b. I wish to limit consent to certain persons and only give consent for contact with the following classes of people:
7. (1) The adopted person YES  NO 
8. (2) The adopted person’s adopted parents YES  NO 
9. (3) The adopted person’s adopted siblings YES  NO 
10. (4) The adopted person’s adopted lineal ancestors YES  NO 
11. (5) The adopted person’s lineal descendants YES  NO 

12. (6) The legal representatives of any of these persons YES  NO 

    1. c. If contact is limited to the legal representative (legal guardian, attorney, etc.) of certain classes of persons, please list which class of persons: _____________________________________________________________________________________ _____________________________________________________________________________________ ADOPTIONS FINALIZED ON AND AFTER MARCH 16, 1951 SECTION 6: TYPES OF CONTACT/RELEASE OF INFORMATION (Complete only if you wish to consent to contact) I wish the following types of contact by those persons requesting contact with me: (Please check all that apply and indicate any limitations or qualifications to these methods of contact.) • Telephone ______________________________________________________________ • Letters _______________________________________________________________ • Personal contact, unannounced ___________________________________________________ • Personal contact, prearranged with me ___, either via phone ___, or correspondence___ • Personal contact through another person. Please give name, relationship to you, if any, and information to be released regarding how to contact: _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ Is the address on PAGE 1 an address a person requesting contact may use to write to you? YES  NO  If no, please share the address to be used: ______________________________, _______________________, ______________, _______ (Street/Rural Route/PO Box) (Town/City) (State) (Zip) • Are the telephone numbers on PAGE 1 number(s) which can be shared with eligible persons requesting contact? YES  NO  • If no, please list telephone number(s), if any, that might be shared and used to contact you. _________________________, _________________________, _______________________ (Work Telephone No.) (Home Telephone No.) (Pager/Cell phone) Other information I wish to have released about me to any eligible persons (please identify to whom and the contents of the information to be provided). _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ ADOPTIONS FINALIZED ON AND AFTER MARCH 16, 1951 SECTION 7: DECLARATION (Must be completed by everyone) I desire to put my name on the Contact Veto Registry, and declare that the information provided is true and correct, to the best of my knowledge. I acknowledge that it is a felony to make false statements in connection with this application. I understand that I will be notified at the mailing address shown on this form of any request for contact with me made by any eligible person. I understand that by registering with the Contact Veto Registry I am not automatically afforded access to adoption records. I understand that this form will become a part of the post adoption record maintained in the Office of the Department of Children’s Services Adoption Services unit. ___________________________________ Signed ___________________________________ Date SECTION 8: ADDITIONAL INFORMATION TO BE SUBMITTED (Everyone must comply) FEES A fee of $25.00 payable for filing or varying the contact veto registration must accompany this completed, signed registration form. If you are unable to pay this fee, you may qualify for a fee waiver as provided by law. [T.C.A. § 36-1-141] Payment may be via cashier’s check, money order, or personal check made payable to the Department of Children’s Services and mailed to Post Adoption Services, 8th Floor, Cordell Hull Building, 436 6th Avenue North, Nashville, TN 37243-1290. PROOF OF IDENTITY Proof of identity must accompany this completed, signed registration form. A copy of a photo license will suffice as sole proof of identity. Other acceptable proof of identity may be copies of: • Full Birth Certificate • Marriage Certificate • Current Passport YOU MAY WISH TO MAKE A COPY OF THIS APPLICATION FOR YOUR FILES BEFORE RETURNING THIS COMPLETED ORIGINAL DOCUMENT TO THE DEPARTMENT OF CHILDREN’S SERVICES. OFFICIAL USE ONLY Received in DCS Post Adoption Services: Day ______ Month _______________ Year _______ ADOPTIONS FINALIZED ON AND AFTER MARCH 16, 1951

13. (3) Contact Veto Registry Application - Adoptive Relative: TENNESSEE DEPARTMENT OF CHILDREN’S SERVICES CONTACT VETO REGISTRY INTRODUCTION I understand that contact with me may be requested by certain classes of eligible persons who, as may be permitted by law, may have access to the sealed records, adoption records, sealed adoption records or post adoption records and those records in any other information source. An adopted person twenty-one (21) years of age or older, or his or her legal representative, is eligible to request access to these records. With the written permission by the adopted person to the Department of Children’s Services, the adopted person’s birth or adopted parents or step-parents, the birth or adopted siblings of the adopted person, lineal ancestors or lineal descendants twenty-one (21) years of age or older, of the adopted person or their legal representative may also obtain access to those records. The class of eligible persons may be revised periodically by changes to the law. 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 adoption record, sealed record, 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. [I understand that no contact may be made through any information contained in the records which I receive. (T.C.A. §§ 36-1-127(f), 36-1-130 and 36-1-131)] 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]. Any person who, after obtaining information from the records, uses such information to cause injury to the person whose name was obtained under this part, commits a Class A misdemeanor [T.C.A. § 36-1-132]. Further, any person who has been injured pursuant to this subsection shall have a cause of action in the Circuit or Chancery Court for injunctive relief and damages, including both compensatory and punitive damages, against any person who uses the information in violation of this subsection. I understand that contact with me by an eligible person is governed by filing my intentions with the Contact Veto Registry. I understand there is a fee for filing with the Contact Veto Registry. 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. [If, however, I cannot be located or do not submit a modification or withdrawal to the contact veto I have previously filed, I understand that my contact veto remains in effect.[T.C.A. § 36-1-130(b)(1)]. ADOPTIONS FINALIZED ON AND AFTER MARCH 16, 1951 I understand that I may vary this contact veto by indicating my desires for contact, if any, with the eligible persons and the means of contact I wish to have with particular eligible persons. [T.C.A. § 36-1-111(k)(3)(b); § 36-1-127-36-1-131]. In doing so, I understand I must write to the address below and request the necessary forms to complete and file with the Contact Veto Registry and pay any necessary fees: CONTACT VETO REGISTRY POST ADOPTION SERVICES TENNESSEE DEPARTMENT OF CHILDREN’S SERVICES 8TH FLOOR, CORDELL HULL BUILDING 436 6TH AVENUE NORTH NASHVILLE, TENNESSEE 37243-1290 CONTACT VETO REGISTRY APPLICATION ADOPTIVE RELATIVE SECTION 1: INFORMATION ABOUT YOURSELF (Everyone must complete this section) CHECK APPROPRIATE BLANK: Initial Filing Varying Previous Filing_____ PLEASE COMPLETE THE FOLLOWING SO THAT YOU MAY BE LOCATED IN THE FUTURE BY THE DEPARTMENT CONCERNING YOUR INTENTIONS REGARDING CONTACT: SECTION 2: DETAILS OF ADOPTIVE RELATIVE Your Present Relationship To Last Name Adopted Person Maiden Name All Previous Last Names First & Middle Name Your Date of Birth / / Place of Birth: County __________ City ______ State ______ Mailing Address Zip Code Telephone No. Home Business ________________________________ _______________________________ Area Code Number Area Code Number ADOPTIONS FINALIZED ON AND AFTER MARCH 16, 1951 The current address and telephone numbers are needed to enable the Department to inform you if any eligible person makes a request for contact. The address does not have to be your residential address (a Post Office Box is sufficient). If you do not have a telephone, please note. SECTION 3: INFORMATION PERTAINING TO THE ADOPTED PERSON Last Name By Adoption First & Middle Names Sex (F__M__) Date of Birth / / Place of Birth: County ___________ City ________ State ___________ Full Name of Adoptive Father Full Name of Adoptive Mother Type of Adoptive Department: ( ) Private/Independent: ( ) Placement Licensed Child-placing Agency: ( ) ____________________________________ Name of Agency Please check one. This information will assist the Department to locate the adoption records, but is not essential. SECTION 4: CONTACT VETO (Complete only if you wish to veto contact)

    1. a. I wish to veto contact with all classes of eligible persons who as may be permitted by law, to have access to the adoption records, sealed records, sealed adoption records or post adoption records to have contact with me. YES  NO  (If checked yes, item “c” must be completed.)
    2. b. The filing of a contact veto by you makes the contact veto automatically applicable to your siblings, lineal descendants, lineal ancestors, and the spouses of those persons so that they cannot be contacted by a person eligible to have the records opened. You may, however, exclude persons in those classes from this automatic coverage so that they will have to register a contact veto themselves or, upon location by the Department, pursuant to a search request, they will have to register a contact veto at that time. [T.C.A. § 36- 1-130(A)(6)]. Please indicate whether you wish to exclude any of these persons.
    3. c. I wish to exclude from the automatic contact veto the following:
14. (1) My siblings or future siblings: YES  NO  (brothers and sisters) ADOPTIONS FINALIZED ON AND AFTER MARCH 16, 1951
15. (2) My lineal descendants: YES  NO  (children and grandchildren)
16. (3) My lineal ancestors: YES  NO  (parents and grandparents)

17. (4) The spouses of my:

    1. (a) myself YES  NO 
    2. (b) siblings YES  NO 
    3. (c) lineal descendants YES  NO 

    4. (d) lineal ancestors YES  NO  If you have marked “YES” in any part of item “c”, please complete the following for any known individuals: Relationship to Person Address Name Completing the Form Street, RR, PO Box, Town, State, Zip SHOULD YOU WISH NO CONTACT WITH ANY OTHER ELIGIBLE PERSONS BUT WISH TO SHARE A STATEMENT OF YOUR FEELINGS, OR CIRCUMSTANCES WHICH IMPACT YOUR DECISION, PLEASE SHARE THAT INFORMATION HERE: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ SECTION 5: CONTACT CONSENT (Complete only if you wish to consent to contact)

       1. a. I give consent for ALL other classes of eligible persons who, as may be permitted by law, to have access to the sealed records, sealed adoption records or post adoption record to have contact with me. YES  NO  ADOPTIONS FINALIZED ON AND AFTER MARCH 16, 1951
       2. b. I wish to limit consent to certain persons and only give consent for contact with the following classes of people:
18. (1) The adopted person’s birth parents YES  NO 
19. (2) The adopted person’s birth siblings YES  NO 
20. (3) The adopted person’s birth lineal ancestors YES  NO 

21. (4) The legal representatives of any of these persons YES  NO 

    1. c. If contact is limited to the legal representative (legal guardian, attorney, etc.) of certain classes of persons, please list which class of persons: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ SECTION 6: TYPES OF CONTACT/RELEASE OF INFORMATION (Complete only if you wish to consent to contact) I wish the following types of contact by those persons requesting contact with me: (Please check all that apply and indicate any limitations or qualifications to these methods of contact.) • Telephone _____________________________________________________________________ • Letters ________________________________________________________________________ • Personal contact, unannounced ___________________________________________________ • Personal contact, prearranged with me ___, either via phone ___, or correspondence ___ • Personal contact through another person. Please give name, relationship to you, if any, and information to be released regarding how to contact: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ • Is the address on PAGE 1 an address a person requesting contact may use to write to you? YES  NO  If no, please share the address to be used: _____________________________, _______________________, ______________, ________ (Street/Rural Route/PO Box) (Town/City) (State) (ZIP) • Are the telephone numbers on PAGE 1 number(s) which can be shared with eligible persons requesting contact? YES  NO  • If no, please list telephone number(s), if any, that might be shared and used to contact you. ______________________, ____________________ ________________________ (Work Telephone No.) (Home Telephone No.) (Pager/Cell phone) ADOPTIONS FINALIZED ON AND AFTER MARCH 16, 1951 Other information I wish to have released about me to any eligible persons (please identify to whom and the contents of the information to be provided). _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ SECTION 7: DECLARATION (Must be completed by everyone) I desire to put my name on the Contact Veto Registry, and declare that the information provided is true and correct, to the best of my knowledge. I acknowledge that it is a felony to make false statements in connection with this application. I understand that I will be notified at the mailing address shown on this form of any request for contact with me made by any eligible person. I understand that by registering with the Contact Veto Registry I am not automatically afforded access to adoption records. I understand that this form will become a part of the post adoption record maintained in the office of the Department of Children’s Services Adoption Services unit. _______________________________________ Signed _______________________________________ Date SECTION 8: ADDITIONAL INFORMATION TO BE SUBMITTED (Everyone must comply) FEES A fee of $25.00 payable for filing or varying the contact veto registration must accompany this completed, signed registration form. If you are unable to pay this fee, you may qualify for a fee waiver as provided by law. [T.C.A. § 36-1-141] Payment may be via cashier’s check, money order, or personal check made payable to the Department of Children’s Services and mailed to Post Adoption Services, 8th Floor, Cordell Hull Building, 436 6th Avenue North, Nashville, TN 37243-1290. PROOF OF IDENTITY Proof of identity must accompany this completed, signed registration form. A copy of a photo license will suffice as sole proof of identity. Other acceptable proof of identity may be copies of: • Full Birth Certificate • Marriage Certificate • Current Passport YOU MAY WISH TO MAKE A COPY OF THIS APPLICATION FOR YOUR FILES BEFORE RETURNING THIS COMPLETED ORIGINAL DOCUMENT TO THE DEPARTMENT OF CHILDREN’S SERVICES. ADOPTIONS FINALIZED ON AND AFTER MARCH 16, 1951 OFFICIAL USE ONLY Received In Post Adoption Services: Date: Day_________ Month___________________ Year_______

Authority: T.C.A. §§ 36-1-101, et seq.; Public Chapter 1079, § 13 (1996); Public Chapter 1068 (1996); and Public Chapter 1054 (1996). Administrative History: Original rule filed October 26, 2001; effective January 9, 2002.