Attorney Fee Disclosure Affidavit

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 ofthe order by the Court. See T.C.A. 36-1-120(b). STATE OF TENNESSEE COUNTY OF SHELBY Being duly sworn according to law, affiant would state: 1. I am ____________________________ , attorney for petitioners ________________________________ (Names ofProspective Adoptive Parents) in the adoption proceeding styled: ____________________________________ which is filed inthe Chancery Court for Shelby County, Tennessee in which they (he/she) have sought to adopt ____________________________________________________________________________ (Name(s) of Child(ren), and inwhich the Court has ordered the entry of an order of adoption pursuant to that petition. 2. The following are fees charged by me or persons who are employed, contracted by, or associated with me for services rendered forthe placement of the child(ren) with the Petitioner(s). (Attach additional sheets if necessary: a. State first the service(s) rendered in the placement of the child(ren) with the petitioner(s) immediately followed by b. The specific fees charged petitioner(s) for each service: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________3. The following are fees charged by me or persons who are employed, contracted by, or associated with me for legal servicesrendered to Petitioner(s) in the adoption proceedings involving the child(ren): (Attach additional sheets if necessary: 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 b. The specific fees charged petitioner(s) for each service: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________4. The following are fees paid by my or persons who are employed, contracted by, or associated with me to any other person orentity for services rendered in securing the placement of the child(ren) with the petitioners or for securing any services related tosecuring any home studies or surrender of the child(ren): a. State first the services rendered by persons or entities whose services assisted in securing the childs (childrens)placement, or for securing a home study or surrender of the child(ren) followed immediately by, b. The specific amount of the fees paid for each service to that person or entity:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________This the ____ day of ____________ , ______ . Please Print: FURTHER AFFIANT SAITH NOT: Attorney for Petitioner(s) Address: Signature: Sworn to and subscribed before me this ____ day of ____________ , ______ . My Commission Expires: ____________________ NOTARY PUBLIC