______Court PETITION FOR ADOPTION Case Number ______County, Tennessee

______Petitioner(s) Respondent(s)

IDENTIFICATION OF THE PARTIES

1. Petitioner(s)

______FULL Name Age Address City State Zip Code

______FULL Name Age Address City State Zip Code The Petitioner(s) are [specify which]  unrelated to the child,  related to the child in the following manner: ______, or  stepparent(s). All marriage and divorce certificates of the Petitioner(s) are attached as an exhibit to this Petition.

2. Respondent(s)

______FULL Name Age Address City State Zip Code ______FULL Name Age Address City State Zip Code The Respondent(s) are [specify any which are applicable]  biological parent(s)  legal guardian(s),  legal custodian(s),  other person(s) entitled to notice  a public or private agency that may have custody or complete or partial guardianship of the child.

3. The Child

______Name Sought to be Confirmed in this Proceeding Birth Date Place of Birth The child's birth certificate is an exhibit to the Petition. PURPOSE OF THIS PETITION

4. The Petitioner(s) desire that the relationship of parent and child be established between them and the child. 5. The Petitioner(s) desire that the child’s name be confirmed as indicated in this Petition. 6. The Petitioner(s) are fit persons to have the care and custody of the child. It is in the best interest of the child for this adoption to occur. They are financially able to provide for the child and will ensure that any physical, emotional or special needs of the child are met. 7. [Specify which.]  The Petitioner(s) have lived in Tennessee for at least the six consecutive months immediately preceding the filing of this Petition.  The Petitioner(s) have lived or maintained a regular place of abode in Tennessee for at least six months immediately prior to entering into military service.  The Petitioner(s) are related to the child and now reside in Tennessee but have not done so for at least the six consecutive months immediately preceding the filing of this Petition. 8. There has been full compliance with the laws regarding surrender of the child to the Petitioner(s), or termination of parental or guardianship rights, or consent to this adoption by the agency with rights to place the child for adoption. Copies of any surrenders of the child to the Petitioner(s), as well as any orders terminating parental or guardianship rights, are attached to this Petition. Alternatively, the Petitioner(s) intend to offer proof sufficient to effect compliance with the requirements for termination of parental or guardianship rights or parental consents as part of this adoption proceeding. 9. The Petitioner(s) have physical custody of the child. Custody was obtained from ______[name of person(s) or agency]. Alternatively, the Petitioners [specify which]  Will receive physical custody of the child from the surrendering parent or guardian within five days of the surrender, as evidenced by the affidavit of the person or persons receiving the surrender and by affidavit of the surrendering or consenting parent or guardian or court order;

 Have the right to receive physical custody of the child upon the child's release from a health care facility as evidenced by an affidavit of the person or persons or entities receiving the child and by the affidavit of the surrendering or consenting parent or guardian or court order; or

 Have a sworn, written statement from the person, the Department of Children’s Services, the licensed child-placing agency, or the child-caring agency that has physical custody, which statement waives the rights to custody in the manner required by law.

PETITION FOR ADOPTION www.selegal.org PAGE 2 10. Except for any property shown on an exhibit attached to this Petition, the child has no right, title or interest in any property, real, personal, or mixed, so far as can be determined by the Petitioner(s).

PARENTAL CONSENT 11. [Specify which.]  The biological parent(s) are giving consent for the adoption of the child by unrelated persons. The biological parent(s) understand that the entry of an order confirming the parental consent, without revoking the parental consent prior to the entry of such order, will terminate the biological parent(s)' parental rights to the child forever and that the biological parent(s) will have no legal rights to custody or control of the child or to visitation with the child in the future.  The biological parent(s) are signing the Petition and understand that the child will be adopted by the relatives or stepparent of the child. They also understand that, in the case of the adoption by relatives, they will have no legal rights to custody or control of the child or to visitation with the child in the future.  The biological parent(s) are dead, and copies of the death certificates are attached to the Petition.  The biological parent(s) are alive and are not giving consent for the adoption of the child.

NOTICE 12. The Petitioner(s) have made inquiry of the Putative Father Registry within ten working days prior to the filing of the Petition to determine whether any person claims a paternity interest in the child by having entered a claim with the registry. Except as may be indicated in an exhibit to this Petition, no one has claimed a paternity interest in the child by filing a claim with the registry. If the child is less than 30 days old at the time this Petition is filed, the Petitioner(s) have provided notice of the filing of this Petition to the registry. 13. [Specify which.]  The child is not subject to the Indian Child Welfare Act because the child's family is not enrolled in an American Indian tribe or Alaskan Eskimo tribe or eligible to be enrolled in such a tribe.  Compliance with the Indian Child Welfare Act is required; notice must be given to the tribe; and the tribe can intervene in the adoption at any time to take jurisdiction. 14. Except as may be indicated in this Petition or an exhibit to it, there are no other persons known to the Petitioner(s) who are entitled to notice of the filing of this Petition or who have a claim or potential claim to the paternity of this child.

CONNECTION OF THE CHILD WITH THE STATE OF TENNESSEE 15. [Specify which.]  The child was not brought into Tennessee for foster care or adoption.  The child was brought into Tennessee for foster care or adoption from another state. There has been full compliance with the Interstate Compact on the Placement of Children. PETITION FOR ADOPTION www.selegal.org PAGE 3 Evidence of compliance in the form of the ICPC Form 100A or other form from the Tennessee Department of Human Services, or a sworn statement stating why such form is not required, is attached as an exhibit to this Petition.  The child was brought into Tennessee for foster care or adoption from another state. There has not been full compliance with the Interstate Compact on the Placement of Children. The reason for noncompliance is explained in an exhibit to this Petition.  The child was brought into Tennessee for foster care or adoption from a foreign country. Evidence is attached as exhibit to this Petition showing approval of the government or legal authority in the country from which the child was brought that the child's placement with the Petitioners was appropriate and that the Petitioners have legal authority under that country's law to have the custody of the child. (Alternatively, the Petitioners have filed as exhibit to this Petition an affidavit and any other available documentary evidence that shows why there is no approval available for the child from the foreign government or legal authority in the foreign country concerning the child's placement with the Petitioners.) In addition, evidence is attached as exhibit to this Petition from the Immigration and Naturalization Service, the Department of Justice, or the Department of State that the child has proper authorization to enter the United States. Petitioners know of no reason why, due to an interpretation of the United States government, the child must be re-adopted under Tennessee law to effect a valid adoption.

PAYMENTS

16. [Specify which.]  The Petitioner(s) have not paid, or promised to pay, any money, fees, contributions, or other remuneration or thing of value in connection with the birth, placement or the adoption of the child. Specifically, no attorney's fees or medical expenses or counseling fees or other expenses permitted by law, or any other fees, remuneration, or contribution, have been paid or promised.  The Petitioner(s) have paid, or promised to pay, money, fees, contributions, or other remuneration or thing of value in connection with the birth, placement or the adoption of the child. The specific amounts, and the specific purposes for which these were paid or promised, are as attached as an exhibit to this Petition. [Include attorney's fees, medical expense, counseling fees, the fees of any licensed child-placing agency or licensed clinical social worker, and the other expenses permitted under §§ 36-1-108 and 36-1-109 of the Tennessee Code Annotated.]

RELIEF SOUGHT FROM THE COURT

Petitioners request: 1. [Specify which.]  Process be served personally upon the Respondent(s).  Process issue by publication requiring the Respondent(s) to answer this Petition. [Note: An affidavit is required concerning efforts to determine the identity and whereabouts of the parties against service of process by publication is sought.]

PETITION FOR ADOPTION www.selegal.org PAGE 4 2. A Final Order of Adoption be entered establishing the relationship of parent and child between the Petitioner(s) and the child. 3. The name of the child be changed and confirmed as indicated above. 4. Any further and general relief to which they are entitled.

SIGNATURE AND VERIFICATION

We declare under penalty of perjury under the laws of the State of Tennessee that the facts stated in this Petition are true to the best of our knowledge and belief.

Dated:______Signature Telephone: ______Fax: ______E-Mail: ______

Dated:______Signature Telephone: ______Fax: ______E-Mail: ______

STATE OF TENNESSEE COUNTY OF ______

Sworn to and subscribed before me this ______day of ______, 20____.

My commission expires: ______Notary Public

PETITION FOR ADOPTION www.selegal.org PAGE 5 CONSENT OF PARENT

I join in the Petition for Adoption filed by ______. I understand that the child will be adopted by [specify which]  relatives of the child  a stepparent of the child  unrelated parties. I also understand that:  In the case of the adoption of the child by relatives, I will have no legal rights to the custody, control, or to visitation with the child in the future.  In the case of the adoption of the child by unrelated persons, the entry of an order confirming my consent to the adoption, without my revoking my consent prior to the entry of such order, will terminate my parental rights to the child forever and I will have no legal rights to custody or control of the child or to visitation with the child in the future.  The act of signing below does not terminate my parental rights until the court has entered an order confirming my consent and until the court requires me to answer, under oath, each of the questions required by statute of parents, including the question regarding the contact veto.  I am entitled to ten calendar days’ written notice by the court of the appearance date for my required response to the court before the entry of the order confirming my consent.

______Signature Telephone: ______Fax: ______E-Mail: ______STATE OF ______COUNTY OF ______

Sworn to and subscribed before me this ______day of ______, 20____.

My commission expires: ______Notary Public

PETITION FOR ADOPTION www.selegal.org PAGE 6 CONSENT OF PARENT

I join in the Petition for Adoption filed by ______. I understand that the child will be adopted by [specify which]  relatives of the child  a stepparent of the child  unrelated parties. I also understand that:  In the case of the adoption of the child by relatives, I will have no legal rights to the custody, control, or to visitation with the child in the future.  In the case of the adoption of the child by unrelated persons, the entry of an order confirming my consent to the adoption, without my revoking my consent prior to the entry of such order, will terminate my parental rights to the child forever and I will have no legal rights to custody or control of the child or to visitation with the child in the future.  The act of signing below does not terminate my parental rights until the court has entered an order confirming my consent and until the court requires me to answer, under oath, each of the questions required by statute of parents, including the question regarding the contact veto.  I am entitled to ten calendar days’ written notice by the court of the appearance date for my required response to the court before the entry of the order confirming my consent.

______Signature Telephone: ______Fax: ______E-Mail: ______

STATE OF ______COUNTY OF ______

Sworn to and subscribed before me this ______day of ______, 20____.

My commission expires: ______Notary Public

PETITION FOR ADOPTION www.selegal.org PAGE 7 ______Court EXHIBITS TO PETITION Case Number ______County, Tennessee FOR ADOPTION

______vs. ______Petitioner(s) Respondent(s)

[Check all that are attached and indicate the exhibit number.]  Exhibit ___ The child's original birth certificate  Exhibit ___ The Petitioners’ marriage certificate  Exhibit ___ The Petitioners’ previous divorce decrees (if they have been married before)  Exhibit ___ The death certificate of each biological parent who is deceased

 Exhibit ___ Copies of any surrenders of the child to the Petitioner(s), as well as any orders terminating parental or guardianship rights  Exhibit ___ A description of the child’s right, title and interest in any property, real, personal, or mixed, so far as can be determined by the Petitioner(s)  Exhibit ___ [specify which]  A statement of the names of persons claiming a paternity interest in the child by filing a claim with the putative father registry or  a statement from the registry that there are no such persons  Exhibit ___ Names and addresses of other persons known to the Petitioner(s) who are entitled to notice of the filing of this Petition  Exhibit ___ Form 100A, another form from the Tennessee Department of Human Services, or a sworn statement stating why such form is not required  Exhibit ___ A statement concerning noncompliance with the Interstate Compact on the Placement of Children  Exhibit ___ Evidence showing approval of the government or legal authority in the country from which the child was brought that the child's placement with the Petitioner(s) was appropriate and that the Petitioner(s) have legal authority under that country's law to have the custody of the child  Exhibit ___ An affidavit and any other available documentary evidence that shows why there is no approval available for the child from the foreign government or legal authority in the foreign country concerning the child's placement with the Petitioner(s)  Exhibit ___ Evidence from the Immigration and Naturalization Service, the Department of Justice, or the Department of State that the child has proper authorization to enter the United States  Exhibit ___ Other: ______.

PETITION FOR ADOPTION www.selegal.org PAGE 8