1. (1) The following form is to be used by a licensed child-placing agency or a licensed clinical social worker to disclose, as required by T.C.A. § 36-1-120(b), the fees charged to the prospective adoptive parents, and must be filed with the proposed order of adoption prior to the entry of the order by the Court.
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: LICENSED CHILD-PLACING AGENCY OR LICENSED CLINICAL SOCIAL WORKER FEE DISCLOSURE STATEMENT TENNESSEE CODE ANNOTATED, § 36-1-120(b) This affidavit must be filed by the licensed child-placing agency or the licensed clinical social worker with the proposed adoption order prior to entry of the order by the Court. See, T.C.A. 36-1-120(b). STATE OF TENNESSEE COUNTY OF _______________ Being duly sworn according to law, affiant would state:

   1. 1. I am ________________________________, an authorized representative of _______________________________________, (Name of Licensed Child-Placing Agency) [or] _____________________________, (Name of Licensed Clinical Social Worker).

   2. 2. My agency [or I] has [have] charged __________________________________________________________________________ (Names of Prospective Adoptive Parent(s)) the following fees or other charges involving the placement of the child(ren): _______________________________________________________________________: (Names of Child(ren))

      1. a. State first the service(s) rendered in the placement of the child(ren) with the petitioner(s) immediately followed by
      2. b. The fees charged petitioner(s) for each specific service. (Attach additional sheets if necessary): _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________

   3. 3. My agency [or I] has [have] charged ________________________________________________________________________ (Names of Prospective Adoptive Parent(s)) the following fees or other charges involving home studies of the prospective adoptive parent(s):

      1. a. State first the service(s) rendered in conducting home studies of the petitioner(s) immediately followed by
      2. b. The fees charged petitioner(s) for each specific service. (Attach additional sheets if necessary): _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________

   4. 4. My agency [or I] has [have] charged ________________________________________________________________________ (Names of Prospective Adoptive Parent(s)) the following fees or other charges involving supervision of the placement of the child(ren) in the home of the prospective adoptive parent(s):

      1. a. State first the service(s) rendered in conducting supervision of the child’s (children’s) placement in the home of the petitioner(s) immediately followed by
      2. b. The fees charged petitioner(s) for each specific service. (Attach additional sheets if necessary): _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ This the ____ day of ______________, 20_____ FURTHER AFFIANT SAITH NOT. Please Print: ______________________________ Authorized Representative of Licensed Child-Placing Agency/or Licensed Clinical Social Worker 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., 36-1-120(b), 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.