1. (1) The following form is to be used by a licensed child-placing agency, the Tennessee Department of Children’s Services or an agency such as another state or federal agency to give consent to the adoption of a child by the prospective adoptive parent(s) to the extent that the agency or Department has either full or partial guardianship based upon a surrender, or other relinquishment of parental rights, or by a termination of those rights by involuntary court action.

2. (2) Form: CONSENT BY A LICENSED CHILD-PLACING AGENCY OR BY THE TENNESSEE DEPARTMENT OF CHILDREN’S SERVICES FOR ADOPTION OF A CHILD T.C.A. §§ 36-1-116(b)(11) and 117(h) STATE OF (___________________) COUNTY OF (_________________) First being duly sworn according to law, affiant would state:

   1. 1. I am, _______________________________, Executive Head of_______________________ _____________________________________ (a licensed child-placing agency); or an authorized representative of the Tennessee Department of Children’s Services; or an authorized representative of ________________________________________________, a state or federal agency with the right to place the child for adoption_________________________________, (Legal Name of Child) D.O.B._____________.
   2. 2. My agency or department holds __full or __ partial guardianship of the child by a surrender or relinquishment of rights by one or both parents or guardians of the child, or by termination of the parental or guardianship rights of one or both parents or guardians.
   3. 3. I am authorized by my agency to give consent to the adoption of this child by: ________________________________ Prospective Adoptive Mother ________________________________ Prospective Adoptive Father
   4. 4. On behalf of my agency, and to the extent of my agency’s full or partial guardianship of: ________________________________________________ (Child’s Name), I give consent to the adoption of this child by the above prospective adoptive parent(s). This ____day of _____________, 20____ FURTHER AFFIANT SAITH NOT. _____________________________________ Print Name: Name of Person Authorized to Give Consent _____________________________________ Title 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., 36-1-116(b)(11), 36-1-117(h), 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.