1. (1) This form must be completed pursuant to T.C.A § 36-1-111(k)(1) under oath before the judge or other person authorized to conduct the surrender proceeding or at the judge’s or person’s direction, the clerk or an employee of the court or person conducting the surrender, prior to the execution of the surrender of a child or prior to the confirmation of the parental consent pursuant to T.C.A. § 36-1-117(g).
2. (2) The completed form shall be kept in a separate file designated for the purpose of maintaining the form until it is forwarded to the court where the adoption petition is filed. The information contained in the form shall be confidential and shall not be disclosed to any other person without the written approval of the court; provided, however, a copy of the information with all identifying information deleted shall be furnished to the adoptive parent(s) or their attorney.
3. (3) Form: MEDICAL/SOCIAL HISTORY FOR CHILD AND CHILD’S FAMILY TENNESSEE CODE ANNOTATED, § 36-1-111(k) This form must be completed under oath prior to execution of the surrender, or prior to confirmation of the parental consent. T.C.A. § 36-1-111(k). When being completed by both the birth mother and birth father, a form is required to be completed by each parent. When one birth parent is completing this form, information about the other birth parent should be completed when that parent is unavailable or refuses to complete the form for her/himself. The legal parents or legal guardians who are not the birth parents of the child should complete information known to them about the birth parents. This form shall be kept by the court in a separate file designated for that purpose until it is forwarded to the court when the adoption petition is filed. The Medical/Social History for Child and Child’s Family shall be confidential and shall not be inspected by any person without the written approval of the court. A copy of this form, with all identifying information deleted shall be given to the prospective adoptive parents or their attorney. T.C.A. § 36-111(k)(1). NOTE: This form may be modified for use outside the State of Tennessee as long as the information requested is provided in the modified form. STATE OF TENNESSEE OR OTHER LOCATION (_________________) COUNTY OF ______________ OR OTHER CITY OR PROVINCE (_____________) Being duly sworn according to law, affiant would state: The following information is true and correct to the best of my knowledge: PERSON COMPLETING THIS FORM: ( ) BIRTH ( ) LEGAL MOTHER’S NAME: ________________________________ ( ) BIRTH ( ) LEGAL FATHER’S NAME: ________________________________ GUARDIAN(S) NAME: ______________________________________________ ADDRESS: _______________________________ __________________ ______ ______ STREET/RURAL ROUTE/P.O. BOX CITY/TOWN STATE ZIP HOME TELEPHONE NO._________ WORK TELEPHONE NO._______ BIRTH MOTHER’S RACE __________ NATIONALITY __________ BIRTH FATHER’S RACE __________ NATIONALITY __________ BIRTH MOTHER’S SOCIAL SECURITY #__________________ DRIVER’S LICENSE # __________________ BIRTH FATHER’S SOCIAL SECURITY # __________________ DRIVER’S LICENSE # __________________ CHILD’S NAME _______________________D.O.B._____ SEX _____ RACE _____ (To indicate race, please use codes of AA (African American), AI (American Indian), AS (Asian), CA (Caucasian), HI (Hispanic) or other (specify) _____________________. To indicate a mixed racial heritage, write in more than one code, for example a child who is African American and Caucasian heritage, write in “AACA.”) IF NATIVE AMERICAN HERITAGE IS INDICATED, PLEASE SPECIFY: TRIBE: _________________________ LOCATION: _________________________ THE PARENT IS REGISTERED ( ) ELIGIBLE TO BE, BUT NOT REGISTERED ( ) WITH THE ABOVE TRIBE. THE CHILD IS REGISTERED ( ) ELIGIBLE TO BE, BUT NOT REGISTERED ( ) WITH THE ABOVE TRIBE. MARRIAGES: (IF PARENT HAS BEEN MARRIED, COMPLETE THE FOLLOWING INFORMATION) NAME OF SPOUSE DATE OF CITY/STATE COUNTY OF LICENSE (INCLUDE MARRIAGE WHERE MARRIAGE MAIDEN NAME) OCCURRED DIVORCES: INCLUDE ANNULMENTS/SEPARATIONS/ANY TYPE DISSOLUTIONMENTS OF MARRIAGE) NAME OF SPOUSE DATE AND TYPE CITY/STATE OF DIVORCE COURT OF DECREE DISSOLUTIONMENT IF MARRIAGE ENDED WITH THE DEATH OF A SPOUSE, PLEASE COMPLETE THE FOLLOWING INFORMATION: NAME OF SPOUSE DATE OF CITY/COUNTY/STATE DEATH WHERE DEATH OCCURRED BACKGROUND INFORMATION FOR ______________________________________ (NAME OF CHILD) INFORMATION CHILD’S BIRTH MOTHER CHILD’S BIRTH FATHER FULL LEGAL NAME ADDRESS STREET/RR/P.O. BOX CITY/TOWN/STATE/ZIP DATE OF BIRTH RACE/ETHNICITY HAIR COLOR EYE COLOR SKIN COLOR WEIGHT HEIGHT EDUCATION (HIGHEST GRADE COMPLETED, VOCATIONAL/ASSOC. COLLEGE DEGREES) PRESENT OCCUPATION: NAME/ADDRESS OF EMPLOYER MILITARY SERVICE: BRANCH OF SERVICE YEARS SERVED DATE OF DISCHARGE TYPE OF DISCHARGE RANK SPECIAL CHARACTERISTICS HOBBIES, INTERESTS AND TALENTS PERSONALITY RELIGION GENERAL HEALTH/HISTORY IF DECEASED CAUSE OF DEATH BACKGROUND INFORMATION FOR ______________________________________ (NAME OF CHILD) INFORMATION BIRTH MOTHER’S MOTHER BIRTH MOTHER’S FATHER FULL LEGAL NAME ADDRESS STREET/RR/P.O. BOX CITY/TOWN/STATE/ZIP DATE OF BIRTH RACE/ETHNICITY HAIR COLOR EYE COLOR SKIN COLOR WEIGHT HEIGHT EDUCATION (HIGHEST GRADE COMPLETED, VOCATIONAL/ASSOC. COLLEGE DEGREES) TYPE EMPLOYMENT MILITARY SERVICE: BRANCH OF SERVICE YEARS SERVED DATE OF DISCHARGE TYPE OF DISCHARGE RANK SPECIAL CHARACTERISTICS HOBBIES, INTERESTS AND TALENTS PERSONALITY RELIGION GENERAL HEALTH/HISTORY IF DECEASED CAUSE OF DEATH AWARE OF PLAN FOR YES ______ NO _____ YES _____ NO _____ ADOPTIVE PLACEMENT BACKGROUND INFORMATION FOR ______________________________________ (NAME OF CHILD) INFORMATION BIRTH FATHER’S MOTHER BIRTH FATHER’S FATHER FULL LEGAL NAME ADDRESS STREET/RR/P.O. BOX CITY/TOWN/STATE/ZIP DATE OF BIRTH RACE/ETHNICITY HAIR COLOR EYE COLOR SKIN COLOR WEIGHT HEIGHT EDUCATION (HIGHEST GRADE COMPLETED, VOCATIONAL/ASSOC. COLLEGE DEGREES) TYPE EMPLOYMENT MILITARY SERVICE: BRANCH OF SERVICE YEARS SERVED DATE OF DISCHARGE TYPE OF DISCHARGE RANK SPECIAL CHARACTERISTICS HOBBIES, INTERESTS AND TALENTS PERSONALITY RELIGION GENERAL HEALTH/HISTORY IF DECEASED CAUSE OF DEATH AWARE OF PLAN FOR YES ______ NO _____ YES _____ NO _____ ADOPTIVE PLACEMENT BACKGROUND INFORMATION FOR ______________________________________ (NAME OF CHILD) INFORMATION BIRTH MOTHER’S MATERNAL BIRTH MOTHER’S MATERNAL GRANDMOTHER GRANDFATHER FULL LEGAL NAME ADDRESS STREET/RR/P.O. BOX CITY/TOWN/STATE/ZIP DATE OF BIRTH RACE/ETHNICITY HAIR COLOR EYE COLOR SKIN COLOR WEIGHT HEIGHT EDUCATION (HIGHEST GRADE COMPLETED, VOCATIONAL/ASSOC. COLLEGE DEGREES) TYPE EMPLOYMENT MILITARY SERVICE: BRANCH OF SERVICE YEARS SERVED DATE OF DISCHARGE TYPE OF DISCHARGE RANK SPECIAL CHARACTERISTICS HOBBIES, INTERESTS AND TALENTS PERSONALITY RELIGION GENERAL HEALTH/HISTORY IF DECEASED CAUSE OF DEATH AWARE OF PLAN FOR YES ______ NO _____ YES _____ NO _____ ADOPTIVE PLACEMENT BACKGROUND INFORMATION FOR ______________________________________ (NAME OF CHILD) INFORMATION BIRTH FATHER’S MATERNAL BIRTH FATHER’S MATERNAL GRANDMOTHER GRANDFATHER FULL LEGAL NAME ADDRESS STREET/RR/P.O. BOX CITY/TOWN/STATE/ZIP DATE OF BIRTH RACE/ETHNICITY HAIR COLOR EYE COLOR SKIN COLOR WEIGHT HEIGHT EDUCATION (HIGHEST GRADE COMPLETED, VOCATIONAL/ASSOC. COLLEGE DEGREES) TYPE EMPLOYMENT MILITARY SERVICE: BRANCH OF SERVICE YEARS SERVED DATE OF DISCHARGE TYPE OF DISCHARGE RANK SPECIAL CHARACTERISTICS HOBBIES, INTERESTS AND TALENTS PERSONALITY RELIGION GENERAL HEALTH/HISTORY IF DECEASED CAUSE OF DEATH AWARE OF PLAN FOR YES ______ NO _____ YES _____ NO _____ ADOPTIVE PLACEMENT BACKGROUND INFORMATION FOR ______________________________________ (NAME OF CHILD) INFORMATION BIRTH MOTHER’S PATERNAL BIRTH MOTHER’S PATERNAL GRANDMOTHER GRANDFATHER FULL LEGAL NAME ADDRESS STREET/RR/P.O. BOX CITY/TOWN/STATE/ZIP DATE OF BIRTH RACE/ETHNICITY HAIR COLOR EYE COLOR SKIN COLOR WEIGHT HEIGHT EDUCATION (HIGHEST GRADE COMPLETED, VOCATIONAL/ASSOC. COLLEGE DEGREES) TYPE EMPLOYMENT MILITARY SERVICE: BRANCH OF SERVICE YEARS SERVED DATE OF DISCHARGE TYPE OF DISCHARGE RANK SPECIAL CHARACTERISTICS HOBBIES, INTERESTS AND TALENTS PERSONALITY RELIGION GENERAL HEALTH/HISTORY IF DECEASED CAUSE OF DEATH AWARE OF PLAN FOR YES ______ NO _____ YES _____ NO _____ ADOPTIVE PLACEMENT BACKGROUND INFORMATION FOR ______________________________________ (NAME OF CHILD) INFORMATION BIRTH FATHER’S PATERNAL BIRTH FATHER’S PATERNAL GRANDMOTHER GRANDFATHER FULL LEGAL NAME ADDRESS STREET/RR/P.O. BOX CITY/TOWN/STATE/ZIP DATE OF BIRTH RACE/ETHNICITY HAIR COLOR EYE COLOR SKIN COLOR WEIGHT HEIGHT EDUCATION (HIGHEST GRADE COMPLETED, VOCATIONAL/ASSOC. COLLEGE DEGREES) TYPE EMPLOYMENT MILITARY SERVICE: BRANCH OF SERVICE YEARS SERVED DATE OF DISCHARGE TYPE OF DISCHARGE RANK SPECIAL CHARACTERISTICS HOBBIES, INTERESTS AND TALENTS PERSONALITY RELIGION GENERAL HEALTH/HISTORY IF DECEASED CAUSE OF DEATH AWARE OF PLAN FOR YES _____ NO _____ YES _____ NO _____ ADOPTIVE PLACEMENT BACKGROUND INFORMATION FOR ______________________________________ (NAME OF CHILD) BIRTH MOTHER’S SIBLINGS FULL LEGAL NAME RELATIONSHIP ADDRESS STREET/RR/P.O. BOX CITY/TOWN/STATE/ZIP DATE OF BIRTH RACE/ETHNICITY HAIR COLOR EYE COLOR SKIN COLOR WEIGHT HEIGHT EDUCATION (HIGHEST GRADE COMPLETED, VOCATIONAL/ASSOC. COLLEGE DEGREES) TYPE EMPLOYMENT MILITARY SERVICE: BRANCH OF SERVICE YEARS SERVED DATE OF DISCHARGE TYPE OF DISCHARGE RANK SPECIAL CHARACTERISTICS HOBBIES, INTERESTS AND TALENTS PERSONALITY RELIGION GENERAL HEALTH/HISTORY IF DECEASED CAUSE OF DEATH AWARE OF PLAN FOR YES ______ NO _____ YES _____ NO _____ ADOPTIVE PLACEMENT BACKGROUND INFORMATION FOR ______________________________________ (NAME OF CHILD) BIRTH FATHER’S SIBLINGS FULL LEGAL NAME RELATIONSHIP ADDRESS STREET/RR/P.O. BOX CITY/TOWN/STATE/ZIP DATE OF BIRTH RACE/ETHNICITY HAIR COLOR EYE COLOR SKIN COLOR WEIGHT HEIGHT EDUCATION (HIGHEST GRADE COMPLETED, VOCATIONAL/ASSOC. COLLEGE DEGREES) TYPE EMPLOYMENT MILITARY SERVICE: BRANCH OF SERVICE YEARS SERVED DATE OF DISCHARGE TYPE OF DISCHARGE RANK SPECIAL CHARACTERISTICS HOBBIES, INTERESTS AND TALENTS PERSONALITY RELIGION GENERAL HEALTH/HISTORY IF DECEASED CAUSE OF DEATH AWARE OF PLAN FOR YES ______ NO _____ YES _____ NO _____ ADOPTIVE PLACEMENT BACKGROUND INFORMATION FOR ______________________________________ (NAME OF CHILD) OTHER CHILDREN BORN TO THE BIRTH MOTHER FULL LEGAL NAME RELATIONSHIP ADDRESS STREET/RR/P.O. BOX CITY/TOWN/STATE/ZIP DATE OF BIRTH RACE/ETHNICITY HAIR COLOR EYE COLOR SKIN COLOR WEIGHT HEIGHT EDUCATION (HIGHEST GRADE COMPLETED, VOCATIONAL/ASSOC. COLLEGE DEGREES) TYPE EMPLOYMENT MILITARY SERVICE: BRANCH OF SERVICE YEARS SERVED DATE OF DISCHARGE TYPE OF DISCHARGE RANK SPECIAL CHARACTERISTICS HOBBIES, INTERESTS AND TALENTS PERSONALITY RELIGION GENERAL HEALTH/HISTORY IF DECEASED CAUSE OF DEATH AWARE OF PLAN FOR YES ______ NO _____ YES _____ NO _____ ADOPTIVE PLACEMENT BACKGROUND INFORMATION FOR ______________________________________ (NAME OF CHILD) OTHER CHILDREN BORN TO THE BIRTH FATHER FULL LEGAL NAME RELATIONSHIP ADDRESS STREET/RR/P.O. BOX CITY/TOWN/STATE/ZIP DATE OF BIRTH RACE/ETHNICITY HAIR COLOR EYE COLOR SKIN COLOR WEIGHT HEIGHT EDUCATION (HIGHEST GRADE COMPLETED, VOCATIONAL/ASSOC. COLLEGE DEGREES) TYPE EMPLOYMENT MILITARY SERVICE: BRANCH OF SERVICE YEARS SERVED DATE OF DISCHARGE TYPE OF DISCHARGE RANK SPECIAL CHARACTERISTICS HOBBIES, INTERESTS AND TALENTS PERSONALITY RELIGION GENERAL HEALTH/HISTORY IF DECEASED CAUSE OF DEATH AWARE OF PLAN FOR YES ______ NO _____ YES _____ NO _____ ADOPTIVE PLACEMENT USE ADDITIONAL PAGES, IF NEEDED, TO DESCRIBE OTHER CHILDREN BORN TO THE BIRTH MOTHER OR BIRTH FATHER PRENATAL HISTORY: MONTH PRENATAL CARE BEGAN _____________________________________ DURING THIS PREGNANCY DID YOU • TAKE ANY MEDICATIONS? Yes ( ) No ( ) • EXPERIENCE PHYSICAL COMPLICATIONS? Yes ( ) No ( ) • HAVE ANY X-RAY, ELECTROCARDIOGRAM OR RADIATION EXPOSURE? Yes ( ) No ( ) IF YES TO ANY OF THE ABOVE, PLEASE EXPLAIN: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ DID YOU HAVE ANY OF THE FOLLOWING DURING THIS PREGNANCY? • GERMAN MEASLES Yes ( ) No ( ) DATE ____________________ • VENEREAL DISEASE Yes ( ) No ( ) DATE ____________________ • VIRUS TYPE _______ Yes ( ) No ( ) DATE ____________________ • INFECTIONS TYPE ________________ Yes ( ) No ( ) DATE ___________ WERE YOU INVOLVED IN ANY ACCIDENTS DURING THIS PREGNANCY? Yes ( ) No ( ) WERE YOU SEXUALLY OR PHYSICALLY ABUSED DURING THIS PREGNANCY? Yes ( ) No ( ) IF YES TO EITHER OF THESE QUESTIONS, PLEASE EXPLAIN: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ DELIVERY HISTORY: DURATION OF LABOR _______________________________ TYPE OF DELIVERY _________________________________ WERE THERE OTHER PREGNANCIES OF THE BIRTH MOTHER: Yes ( ) No ( ) IF YES, PLEASE DESCRIBE THE PREGNANCY AND HOW THE PREGNANCY ENDED (ABORTION, STILLBIRTH, MISCARRIAGES, ETC.) ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ MEDICAL HISTORY FOR ______________________________________________ NAME OF BIRTH MOTHER ( ) BIRTH FATHER ( ) NAME OF CHILD: ______________________________________________________ PLEASE INDICATE BY A CHECK MARK (X) IF YOU OR ANY BIRTH RELATIVE LISTED ON PAGES 3 THROUGH 13 HAVE EVER BEEN DIAGNOSED WITH THE FOLLOWING MEDICAL PROBLEMS. EXPLAIN IN THE “COMMENTS” SECTION THE SPECIFICS OF THE ILLNESS, THE SEVERITY OF THE ILLNESS, AGE AT ONSET OF ILLNESS, TYPE OF TREATMENT AND OUTCOME. MEDICAL CONDITION SELF YES - OTHER COMMENTS RELATIVE YES NO (SPECIFY) ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS) ALCOHOLISM ALLERGIES ARTHRITIS BONE DISEASE CANCER CEREBRAL PALSY CLEFT PALATE CONGENITAL DEFECTS CORONARY (HEART) PROBLEMS CYSTIC FIBROSIS DEAFNESS MEDICAL SELF YES - OTHER COMMENTS CONDITION RELATIVE YES NO (SPECIFY) DIABETES EAR INFECTIONS ECZEMA EPILEPSY/ SEIZURES GONORRHEA/ SYPHILIS HAY FEVER/ ASTHMA HEARING PROBLEMS HEART PROBLEMS HEMOPHILIA HERPES HODGKIN’S HORMONE DISORDER HYPERTENSION KIDNEY DISEASE MENTAL ILLNESS MENTAL RETARDATION MIGRAINES MULTIPLE SCLEROSIS MUSCULAR DYSTROPHY NARCOTIC ADDICTION MEDICAL SELF YES - OTHER COMMENTS CONDITION RELATIVE YES NO (SPECIFY) OTHER PARALYSIS OTHER MEDICAL CONDITION: (SPECIFY) OTHER SUBSTANCE ABUSE RESPIRATORY DISEASE SPEECH PROBLEMS SICKLE-CELL ANEMIA STROKE VISUAL PROBLEMS SUBSTANCE USE HISTORY - BIRTH MOTHER TOBACCO: DO YOU SMOKE? YES ( ) NO ( ) IF YES, DESCRIBE HOW MUCH YOU SMOKE: ___________________ DID YOU SMOKE DURING THIS PREGNANCY? YES ( ) NO ( ) IF YES, FREQUENCY OF HABIT: _________________________________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ALCOHOL: DO YOU DRINK ALCOHOL? YES ( ) NO ( ) DID YOU DRINK DURING THIS PREGNANCY? YES ( ) NO ( ) IF YES TO EITHER QUESTION, DESCRIBE YOUR DRINKING HABITS, (I.E. FREQUENCY, TYPE ALCOHOL USED, HISTORY OF ALCOHOL USE). ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ DRUGS: HAVE YOU EVER USED DRUGS? YES ( ) NO ( ) IF YES, DESCRIBE YOUR DRUG USE, (I.E. TYPE OF DRUG YOU USED, FREQUENCY OF USE, HISTORY OF DRUG USE INCLUDING EXPERIMENTAL USE). _________________________________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ DID YOU USE DRUGS DURING THIS PREGNANCY? YES ( ) NO ( ) IF YES, DESCRIBE YOUR DRUG USE (INCLUDING PRESCRIPTION DRUGS) TYPE OF DRUG, FREQUENCY OF USE AND WHEN THE DRUG WAS USED. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ SUBSTANCE USE HISTORY - BIRTH FATHER ALCOHOL: DO YOU DRINK ALCOHOL? YES ( ) NO ( ) IF YES, DESCRIBE YOUR DRINKING HABITS, (I.E., FREQUENCY, TYPE ALCOHOL USED, HISTORY OF ALCOHOL USE). ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ DRUGS: HAVE YOU EVER USED DRUGS? YES ( ) NO ( ) IF YES, DESCRIBE YOUR DRUG USE, (I.E. TYPE OF DRUG YOU USE, FREQUENCY OF USE, HISTORY OF DRUG USE) DESCRIBE SPECIFIC DRUGS AND TIME FRAMES OF YOUR USE OF EACH DRUG. (INCLUDE EXPERIMENTAL USE.) ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ PSYCHIATRIC HISTORY: BIRTH MOTHER ( ) BIRTH FATHER ( ) HAVE YOU EVER RECEIVED PSYCHOLOGICAL OR PSYCHIATRIC TREATMENT? YES ( ) NO ( ) HAVE YOU EVER TAKEN PSYCHIATRIC MEDICATION? YES ( ) NO ( ) IF YES TO EITHER QUESTION, DESCRIBE TREATMENT ISSUES, DIAGNOSIS, LENGTH OF TREATMENT AND LIST MEDICATIONS USED DURING TREATMENT: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ OTHER INFORMATION YOU WOULD LIKE TO SHARE ABOUT YOURSELF, YOUR SOCIAL/MEDICAL HISTORY, YOUR BIRTH RELATIVES OR ABOUT THE CIRCUMSTANCES IMPACTING YOUR DECISION TO PLACE YOUR CHILD FOR ADOPTION: (IF ADDITIONAL SPACE IS NEEDED, PLEASE ATTACH SHEETS.) Birth/Legal Mother: Birth/Legal Father: Legal Guardian(s): FURTHER AFFIANT SAITH NOT. This _____ day of ___________, 20____ Signature: ____________________________________ Parent or Legal Guardian Sworn to and subscribed before me this _____ day of ____________, 20____ ____________________________________ NOTARY PUBLIC My Commission Expires: _____________________ OR Please Print: ___________________________________ ____Chancellor ____Circuit Judge ___Juvenile Court Judge ____Warden or ___ Judge or ___Clerk of Court of Record In another State; or ___ U.S. Foreign Service Officers or ___ Officers of the United States Armed Forces Authorized to Administer Oaths Signature: ____________________________________ When this form is being completed by DCS staff for pre-placement information purposes, and not as a part of the surrender process, the person completing the form should sign and date the form. Signature: _________________________ County: _____________ Date: _________

Authority: T.C.A. §§ 4-5-201, et seq., 36-1-111(k), and 36-117(g); Public Chapter 532 (1995); and Executive Order #6, January 12, 1996. Administrative History: Original rule filed September 7, 2001; effective November 21, 2001.