1. (1) The following form is used for certification of the completion of any legal counseling requested pursuant to T.C.A. § 36-1-111(k)(2)(F) by the person who is surrendering the child for adoption or who is executing a parental consent to unrelated persons and must be filed with the surrender or parental consent before the surrender is executed before the court by the surrendering person, or before an order of guardianship is entered based upon a surrender or a parental consent to unrelated persons.
2. (2) This information shall be confidential and shall only be disclosed as provided by T.C.A. §§ 36-1-101 et seq.

3. (3) Form: CERTIFICATION OF COMPLETION OF LEGAL COUNSELING RELATED TO ADOPTION PLACEMENT DECISION BY PARENT(S) TENNESSEE CODE ANNOTATED, § 36-1-111(l)(2) and (o) If the person surrendering the child(ren) for adoption, or executing a parental consent to unrelated persons, has requested that the prospective adoptive parent(s) provide legal counseling with regard to the decision of that person to surrender the child for adoption, this certification form must be completed by the attorney who provided such counseling before the surrender is executed or before an Order of Guardianship is entered based upon a surrender or parental consent. See, T.C.A. § 36-1-111(l)(2) and (o). 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 ( ________________) COUNTY OF ____________ Being duly sworn according to law, affiant would state:

   1. 1. I am __________________________________, (Name of attorney providing legal counseling to surrendering person). I am licensed to practice law in the State of Tennessee (or such other State or Country as may be applicable. Please specify.) ___________________________. My Board of Professional Responsibility Number (or other licensing registration number) is ______________.
   2. 2. I was employed by, __________________________________ (Name of person(s) employing attorney to provide legal counseling to surrendering person) to provide legal advice to ___________________________________ (Name of person to whom legal advice was rendered) regarding the legal issues surrounding the decision by this person to place ________________________________________ (Name(s) of the child(ren) for adoption.)
   3. 3. I certify that I have completed an explanation of any questions posed by _______________________________________ (Name of person to whom legal advice was rendered), and that legal counseling has been completed, and they have stated to me that they understand such issues and their rights, and that they wish to proceed with the plan to surrender the above- named child. This the ____ day of ______________, 20_____ FURTHER AFFIANT SAITH NOT. Please Print: ______________________________ Attorney Providing Legal Counsel to Surrendering Person Address: ______________________________ ______________________________ ______________________________ Signature: ______________________________ Sworn to and subscribed before me this _____ day of ____________, 20____ ____________________________ NOTARY PUBLIC My Commission Expires:____________________

Authority: T.C.A. §§ 4-5-201, et seq., 36-1-111(k)(l)(2)(m) and (o), 36-1-117(g), 36-1-125, and 36-1-141; Public Chapter 532 (1995); and Executive Order #6, January 12, 1996. Administrative History: Original rule filed September 7, 2001; effective November 21, 2001.