1. (1) The following form contains information required by T.C.A. §36-1-116(b)(16) to be filed by the prospective adoptive parents with the adoption petition concerning payments made to birth parents and other persons related to the birth of the child, fees paid to child-placing agencies, to attorneys, for counseling for the parents, and for any other fees and expenses in relation to the child’s placement with them, and may be filed as an exhibit to the petition.
2. (2) This information shall be confidential and shall only be disclosed as provided by T.CA. §§ 36- 1-101 et seq.

3. (3) Form: PAYMENT DISCLOSURE FORM FOR USE IN PETITION FOR ADOPTION TENNESSEE CODE ANNOTATED, § 36-1-116(b)(16) This form must be filed with the adoption petition. See, T.C.A. § 36-1-116(b)(16). STATE OF TENNESSEE COUNTY OF _____________ Being duly sworn according to law, affiant(s) would state:

   1. 1. I am/We are ___________________________________ (Name of Prospective Adoptive Mother) and ________________________________ (Name of Prospective Adoptive Father), the petitioner(s) seeking the adoption of _________________________________ (Name of Child) pursuant to a petition for adoption filed in the _____________ Court for __________________, County, Tennessee.

   2. 2. I/We have paid or promised to pay the following money, fees, contributions, or other remuneration or thing of value in the connection with the birth, placement, or adoption of this child (Attach additional sheets as necessary):

      1. a. Medical or hospital expenses of birth mother and child.(Attach Additional Sheets If Necessary):
4. (1) Entities or Persons who received payments, contributions, fees, or other things of value;
5. (2) The specific amount of payments, contributions, fees, or value of things given; and,

6. (3) The specific purpose of payments, contributions, fees, or other things of value: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

   1. b. Other birth-related expenses (Attach Additional Sheets If Necessary):
7. (1) Entities or Persons who received payments, contributions, fees, or other things of value;
8. (2) The specific amount of payments, contributions, fees, or value of things given; and,

9. (3) The specific purpose of payments, contributions, fees, or other things of value: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

   1. c. Expenses paid to or on behalf of the child’s parent(s) including, but not limited to, housing, food, maternity clothing, child’s clothing, utilities, transportation (Attach Additional Sheets If Necessary):
10. (1) Entities or Persons who received payments, contributions, fees, or other things of value;
11. (2) The specific amount of payments, contributions, fees, or value of things given; and,

12. (3) The specific purpose of payments, contributions, fees, or other things of value: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

    1. d. Fees or payments paid to any attorney-at-law and other costs of legal proceedings in connection with the birth, placement, or litigation for the adoption of this child (Attach Additional Sheets If Necessary):
13. (1) Entities or Persons who received payments, contributions, fees, or other things of value;
14. (2) The specific amount of payments, contributions, fees, or value of things given; and,

15. (3) The specific purpose of payments, contributions, fees, or other things of value: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

    1. e. Counseling paid for on behalf of the birth or prospective adoptive parent(s) or child (Attach Additional Sheets If Necessary):
16. (1) Entities or Persons who received payments, contributions, fees, or other things of value;
17. (2) The specific amount of payments, contributions, fees, or value of things given; and,

18. (3) The specific purpose of payments, contributions, fees, or other things of value: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

    1. f. Fees or payments paid to any licensed child-placing agency or licensed clinical social worker (Attach Additional Sheets If Necessary):
19. (1) Entities or Persons who received payments, contributions, fees, or other things of value;
20. (2) The specific amount of payments, contributions, fees, or value of things given; and,

21. (3) The specific purpose of payments, contributions, fees, or other things of value: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

    1. g. Any other money, fees, contributions, or other remuneration or thing of value in connection with the birth, placement, or adoption of this child, given or paid, to the child’s parent(s) or family member(s) (Attach Additional Sheets If Necessary):
22. (1) Entities or Persons who received payments, contributions, fees, or other things of value;
23. (2) The specific amount of payments, contributions, fees, or value of things given; and,
24. (3) The specific purpose of payments, contributions, fees, or other things of value: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ FURTHER AFFIANT(S) SAITH NOT. This the _____ day of ____________, 20_____ Please Print: _______________________________ Prospective Adoptive Mother Signature: _______________________________ Please Print: _______________________________ Prospective Adoptive Father 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., 36-1-116(b)(16), 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.