1. (1) The following form is used to obtain the consent of a child who is fourteen (14) years of age or older to his or her adoption as required by T.C.A. § 36-1-117(i).
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: CONSENT TO ADOPTION BY MINOR WHO IS FOURTEEN (14) YEARS OF AGE OR OLDER TENNESSEE CODE ANNOTATED, § 36-1-117(i) STATE OF TENNESSEE COUNTY OF ________________ Being duly sworn according to law, affiant would state:

   1. 1. I am __________________________________________, (Use the Name of Minor Child Prior to Any Name Change Requested in the Petition, Fourteen (14) Years of Age or Older), Born ___________________ (Date of Birth).
   2. 2. I understand that ________________________________, (Name of Prospective Adoptive Mother), and __________________________________, (Name of Prospective Adoptive Father) have filed a Petition to adopt me.
   3. 3. I understand that if the Court enters an order of adoption based upon the Petition, that I will become the legal child of _______________________________, (Name of Prospective Adoptive Mother), and ________________________________, (Name of Prospective Adoptive Father), and that they will become my parent(s) for all purposes, just the same as if I had originally been born to them (him/her).
   4. 4. I understand that, while I remain under eighteen (18) years of age, my adoptive parent(s) will have the right to determine if I should contact or visit with anyone in my birth family.
   5. 5. I understand that I will have the right to inherit property from my adoptive parent(s), and their (his/her) descendants will have the right to inherit property from me or my descendants but only for property I acquire after the adoption order is entered. After the order of adoption is entered, I will not inherit property from my birth family, nor will they inherit property from me after the order of adoption is entered. I may inherit from or through a parent whose rights were not terminated before his or her death.
   6. 6. No one has pressured me to agree to this adoption, and I believe that my adoption by _______________________________, (Name of Prospective Adoptive Mother), and ______________________________, (Name of Prospective Adoptive Father), is in my best interests. I wish for the adoption to take place.
   7. 7. I freely and voluntarily, without pressure from anyone, consent to this adoption. This the _____ day of ____________, 20______ FURTHER AFFIANT SAITH NOT Please Print: ____________________________________ Name of Minor Child Signature: ____________________________________ Sworn to and subscribed before me this _____ day of __________, 20_____ Please Print:____________________________________ ___ Chancellor ___ Circuit Judge of the ____________ Court for ________________ County, Tennessee. Signature: ____________________________________

Authority: T.C.A. §§ 4-5-201, et seq., 36-1-117(i), 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. Amendment filed March 10, 2005; effective July 29, 2005.