1. (1) The following form is used to by an attorney 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 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: ATTORNEY FEE DISCLOSURE AFFIDAVIT TENNESSEE CODE ANNOTATED, § 36-1-120(b) This affidavit must be filed by the attorney representing the petitioners 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 _______________________________, attorney for petitioners _______________________________________________ (Names of Prospective Adoptive Parents) in the adoption proceeding styled: _______________________________________________________ which is filed in the _______________ Court for ________________, County, Tennessee in which they (he/she) have sought to adopt ________________________________________________________________________________________________ (Name(s) of Child(ren)), and in which the Court has ordered the entry of an order of adoption pursuant to that petition.

   2. 2. The following are fees charged by me or persons who are employed, contracted by, or associated with me for services rendered for the placement of the child(ren) with the Petitioner(s). (Attach additional sheets if necessary):

      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 specific fees charged petitioner(s) for each service: _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________

   3. 3. The following are fees charged by me or persons who are employed, contracted by, or associated with, me for legal services rendered to Petitioner(s) in the adoption proceedings involving the child(ren): (Attach additional sheets if necessary):

      1. a. State first the legal service(s) rendered in the proceedings for the adoption of the child(ren) by the petitioner(s) immediately followed by
      2. b. The specific fees charged petitioner(s) for each service: _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________

   4. 4. The following are fees paid by me or persons who are employed, contracted by, or associated with, me to any other person or entity for services rendered in securing the placement of the child(ren) with the petitioners or for securing any services related to securing any home studies or surrender of the child(ren):

      1. a. State first the services rendered by persons or entities whose services assisted in securing the child’s (children’s) placement, or for securing a home study or surrender of the child(ren) followed immediately by,
      2. b. The specific amount of the fees paid for each service to that person or entity: _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ This the ____ day of ______________, 20_____ FURTHER AFFIANT SAITH NOT. Please Print: ______________________________ Attorney for Petitioner(s) 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.