PETITION FOR

TERMINATION OF
PARENTAL RIGHTS

________________ Court
_______________ County,
Tennessee

Case Number

_____________________________________ _____________________________________
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).
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), or other person(s) entitled to notice.
3.

The Child

_____________________________________________________________________________
Name on Birth Certificate
Birth Date
The child's birth certificate is an exhibit to the Petition. [specify any which are applicable]
The childs current residence address is ____________________________________.
The childs county of residence is _________________________________________.
The child is in the custody of the Department of Human Services

 The child is in the custody of a licensed child-placing agency, namely ____________.

4.
The following facts form the basis for termination of parental rights and bring the
child and parties within the jurisdiction of the court: ________________________________
_____________________________________________________________________________.
PRELIMINARY MATTERS
5.
The Putative Father Registry maintained by the Department of Human Services has
been consulted within ten working days of the filing of this Petition. [specify which] There is
no claim in the Registry to the paternity of the child who is the subject of this Petition. There
is a claim in the Registry filed by __________________________________________________.
6.
There is no other claim or potential claim to the paternity of the child, except
_____________________________________________________________________________.
7.
No parental or guardianship rights have been terminated by surrender, parental
consent, or otherwise, and none must be terminated before the child can be made available for
adoption, except _______________________________________________________________.
8.

All notice required by law has been given.

9.
The medical and social history of the child and the child's biological family has
been completed to the extent possible on the form promulgated by the Tennessee Department of
Childrens Services.
EFFECTS OF THIS PROCEEDING
10. This Petition, if granted, will have the effect of forever severing all of the rights,
responsibilities, and obligations of the parent(s) or guardian(s) to the child and of the child to the
parent(s) or guardian(s).
11. The child will be placed in the guardianship of other person, persons or public or
private agencies who, or that, as the case may be, will have the right to adopt the child, or to
place the child for adoption and to consent to the child's adoption.
12. If the relief sought in this Petition is granted, the parent(s) or guardian(s) will have
no further right to notice of proceedings for the adoption of the child by other persons. The
parent(s) or guardian(s) will have no right to object to the child's adoption or thereafter, at any
time, to have any relationship, legal or otherwise, with the child.
GROUNDS FOR TERMINATION
13.

The following grounds for termination exist:

PETITION FOR TERMINATION OF PARENTAL RIGHTS

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 Abandonment by the parent(s) or guardian(s) has occurred.

There has been substantial noncompliance by the parent(s) or guardian(s) with the
statement of responsibilities in a permanency plan.
The child has been removed from the home of the parent(s) or guardian(s) by order of a
court for a period of six months and:
The conditions that led to the child's removal or other conditions that in all reasonable
probability would cause the child to be subjected to further abuse or neglect and that,
therefore, prevent the child's safe return to the care of the parent(s) or guardian(s), still
persist;
There is little likelihood that these conditions will be remedied at an early date so that
the child can be safely returned to the parent(s) or guardian(s) in the near future; and
The continuation of the relationship between the parent(s) or guardian(s) and child
greatly diminishes the child's chances of early integration into a safe, stable and
permanent home.
The parent(s) or guardian(s) have committed severe child abuse against the child or
against any sibling or half-sibling of the child, or any other child residing temporarily or
permanently in the home of the parent(s) or guardian(s).
The parent(s) or guardian(s) have been sentenced to more than two years' imprisonment
for severe child abuse against the child or against any sibling or half-sibling of the child or
any other child residing temporarily or permanently in the home of the parent(s) or
guardian(s).
The parent has been confined in a correctional or detention facility under a sentence of
ten or more years, and the child was under eight years of age at the time the sentence was
entered by the court.
The parent has been convicted of or found civilly liable for the intentional and wrongful
death of the child's other parent or legal guardian.
The parent or guardian of the child is incompetent to adequately provide for the further
care and supervision of the child because the parent's or guardian's mental condition is
presently so impaired and is so likely to remain so that it is unlikely that the parent or
guardian will be able to assume or resume the care of and responsibility for the child in the
near future.
The Respondent is not the legal parent or guardian of such child or is described in 36-1117(b) or (c) of the Tennessee Code Annotated and . . .
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 The person has failed, without good cause or excuse, to pay a reasonable share of
prenatal, natal, and postnatal expenses involving the birth of the child in accordance
with the person's financial means promptly upon the person's receipt of notice of the
child's impending birth;
The person has failed, without good cause or excuse, to make reasonable and consistent
payments for the support of the child in accordance with the child support guidelines
promulgated by the Department of Human Services;
The person has failed to seek reasonable visitation with the child, and if visitation has
been granted, has failed to visit altogether, or has engaged in only token visitation;
The person has failed to manifest an ability and willingness to assume legal and
physical custody of the child;
Placing custody of the child in the person's legal and physical custody would pose a risk
of substantial harm to the physical or psychological welfare of the child; or
The person has failed to file a petition to establish paternity of the child within 30 days
after notice of alleged paternity by the child's mother, or as required by statute, or after
making a claim of paternity pursuant to statute.
The parent has been convicted of aggravated rape or rape from which the child was
conceived.
Other statutory ground [specify] _____________________________________________.
PURPOSE OF THIS PETITION
14. The Petitioner(s) desire that the relationship of parent and child be established
between them and the child. They also desire that the childs name be changed as indicated in
this Petition.
15. 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.
16. [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) 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.
17.
Petitioner(s),
agency with
Petitioner(s),

There has been full compliance with the laws regarding surrender of the child to the
or termination of parental or guardianship rights, or consent to this adoption by the
rights to place the child for adoption. Copies of any surrenders of the child to the
as well as any orders terminating parental or guardianship rights, are attached to

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this Petition.
18. 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 Human 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.
19. 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).
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.
2.
A Final Order be entered terminating the relationship of parent and child between
the Respondent(s) and the child.
3.

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 Complaint are true to the best of our knowledge and belief.

_________________________________________
Petitioner
Telephone: _________________________
Fax: ______________________________
E-Mail: ____________________________
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_________________________________________
Petitioner
Telephone: _________________________
Fax: ______________________________
E-Mail: ____________________________

STATE OF TENNESSEE
COUNTY OF _________________
Sworn to and subscribed before me this ________ day of ____________________, 20____.
My commission expires: _____________

____________________________________
Notary Public

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