1. (1) The following form is used to obtain the consent of a guardian ad litem of a mentally disabled child who is fourteen (14) years of age or older for the adoption of that child 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 BY GUARDIAN AD LITEM TO ADOPTION OF MENTALLY DISABLED MINOR WHO IS FOURTEEN (14) YEARS 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, _________________________________, Guardian Ad Litem for the minor child, ________________________________________, who is fourteen (14) years of age or older and is mentally disabled.
   2. 2. I have been appointed by this Court to represent the best interests of this child in the petition for his/her adoption by _______________________________________, (Name of Prospective Adoptive Mother), and __________________________________, (Name of Prospective Adoptive Father). * See Note Below
   3. 3. I have investigated the circumstances of the proposed adoption, and have attached hereto my written report giving the basis for my decision to give or withhold consent to the adoption of this child by the petitioners.
   4. 4. Based upon my investigation and report, I  give consent /  withhold consent to the adoption of ___________________________, (Name of Child) by the petitioners. This the _____ day of ____________, 20_____ FURTHER AFFIANT SAITH NOT. Please Print: ______________________________ (Name of Guardian Ad Litem) Address: ______________________________ ______________________________ ______________________________ Signature: ______________________________ Sworn to and subscribed before me this the _____day of ______________, 20_____ ____________________________________ NOTARY PUBLIC My Commission Expires: _______________ NOTE TO THE COURT: A guardian ad litem must be appointed by the court to represent the child before this consent is received, and must be present at the time the consent is received by the Court. The consent shall be filed with the record of this case. The consent must be recited in the order of adoption T.C.A. § 36-1-117(i).

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.