1. (1) The following form is used to obtain the consent of a guardian ad litem or guardian or conservator to the adoption of a mentally disabled adult as required by T.C.A § 36-1-117(j).
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, GUARDIAN OR CONSERVATOR TO ADOPTION OF MENTALLY DISABLED ADULT TENNESSEE CODE ANNOTATED, § 36-1-117(j) STATE OF TENNESSEE COUNTY OF _________________ Being duly sworn according to law, affiant would state:

   1. 1. I am, _________________________________, Guardian Ad Litem, Guardian or Conservator for, ________________________________________, an adult who is mentally disabled.
   2. 2. (Guardian Ad Litem only) I have been appointed by this Court to represent the best interests of this disabled adult in the petition for his/her adoption by _______________________________________, (Name of Prospective Adoptive Mother), and __________________________________, (Name of Prospective Adoptive Father).
   3. 3. (Guardian Ad Litem only) 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 disabled adult by the petitioners.
   4. 4. (Guardian Ad Litem only) Based upon my investigation and report, I  give consent /  withhold consent to the adoption of ___________________________, (Name of Disabled Adult) by the petitioners.
   5. 5. As Guardian or Conservator, I  give consent/  withhold consent to the adoption of ______________________________, (Name of Disabled Adult) by the petitioners. This the _____ day of ____________, 20_____ FURTHER AFFIANT SAITH NOT. Please Print: ______________________________ (Name of Guardian Ad Litem, Guardian or Conservator) Address: _______________________________ _______________________________ _______________________________ Signature: ________________________________ Sworn to and subscribed before me this the _____ day of ______________, 20_____ ___________________________________ NOTARY PUBLIC My Commission Expires: _______________

Authority: T.C.A. §§ 4-5-201, et seq., 36-1-117(j), 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.