This required section provides the name and date of the document being revoked as well as specific personal identification of the Principal. Press [Ctrl+F1] for more information.
This required section provides the Principal's signature and the names and addresses of two witnesses acknowledging the execution and signing of this document.
This required section lists the individuals receiving a copy of the revocation. The revocation is not effective until the health care agent and/or the health care provider is informed of the revocation.
Times New Roman
Revocation of Health Care POA
REVHCP
The Revocation of Health Care Power of Attorney is a document under which a person revokes a Health Care Power of Attorney by declaring that the document will no longer be effective.
Enter the Principal's city or edit the information as desired.
Enter the Principal's state/province or edit the information.
Enter the name of the person who made the Health Care Power of Attorney (the "Principal", or the "Declarant") or edit the information as desired. Use the P.I. Manager to select and paste a record.
RHC01
! Power Revoked Section (1 of 3)
REVOCATION OF
[NAME OF HEALTH CARE POWER OF ATTORNEY AS IT APPEARS ON THE DOCUMENT]
I, ! of
!, ! !,
! Country: !,
! SSN: !,
hereby revoke my ! dated !. The power and authority granted under the ! for making health care decisions on my behalf is revoked and withdrawn and this document provides notice of such revocation.
Enter the title of the Power of Attorney exactly as it appears in the document that will be revoked. (The title of this revocation will be centered when previewed or printed.) Press [Ctrl+F1] for more information.
Enter the name of the person who made the Health Care Power of Attorney (the "Principal", or the "Declarant") or edit the information as desired. Use the P.I. Manager to select and paste a record.
Enter the Principal's street address or edit the information as desired.
Enter the Principal's extended street address or edit the information as desired.
Enter the Principal's city or edit the information as desired.
Enter the Principal's state/province or edit the information.
Enter the Principal's zip/postal code or edit the information as desired.
Enter an X to include the Principal's country, if outside the United States.
Enter the country or edit the information as desired.
Enter an X to include the Principal's social security number. Many health care facilities file their records, including Health Care Powers of Attorney, by the Principal's social security number.
Enter the Principal's social security number or edit the information as desired.
Using the format MM/DD/YYYY, enter the date of the Health Care Power of Attorney. This is the date that the Health Care Power of Attorney was signed, and should be the same date that is shown on the Health Care Power of Attorney.
RHC02
! Signature Section (2 of 3)
[NOTE: Most states have criminal/civil penalties for falsification of a revocation.]
Dated this _____ day of _______________, 19___, at !, !.
! [Required text for Wyoming. Witness signatures follow.]
I declare under penalty of perjury under the laws of Wyoming that the person who signed or acknowledged this document is personally known to me to be the principal, that the principal signed or acknowledged this Revocation of Durable Power of Attorney in my presence, that the principal appears to be of sound mind and under no duress, fraud, or undue influence, that I am not the person appointed as attorney-in-fact, and that I am not a treating health care provider, an employee of a treating health care provider, the operator of a community care facility, an employee of an operator of a community care facility, the operator of a residential care facility, nor an employee of an operator of a residential care facility. I further declare under penalty of perjury under the laws of Wyoming that I am not related to the principal by blood, marriage, or adoption, and, to the best of my knowledge, I am not entitled to any part of the estate of the principal upon the death of the principal under a will now existing or by operation of law.
Enter the city where the revocation will be signed or edit the information as desired.
Enter the state/province where the revocation will be signed or edit the information as desired.
A witness signature is optional in all states except Wyoming. The program selects this option if you indicated that your state is Wyoming. Enter an X if you reside in another state and want to include witness signatures.
This text is only valid for Wyoming. This option is selected if you indicated that your state is Wyoming. Wyoming requires that at least one "disinterested" person witness the revocation. Note the limitations on who may serve as witnesses.
Enter the FIRST witness' name or use the P.I. Manager to select and paste a record. The following information regarding the name and address of the witness may be left blank and be completed when the document is signed. Press [Ctrl+F1] for more information.
Enter the witness' street address or edit the information as desired.
Enter the witness' extended street address or edit the information as desired.
Enter the witness' city or edit the information as desired.
Enter the witness' state/province or edit the information as desired.
Enter the witness' zip/postal code or edit the information as desired.
Enter an X to include the witness' country if outside the United States.
Enter the country or edit the information as desired.
Enter the SECOND witness' name or use the P.I. Manager to select and paste a record. The following information regarding the name and address of the witness may be left blank and be completed when the document is signed.
Wyoming,WY,Wy,Wy.,Wyo,Wyo.
Wyoming,WY,Wy,Wy.,Wyo,Wyo.
RHC03
! Notification Section (3 of 3)
[Copies of this revocation should be given to anyone who has a copy of your health care power of attorney. Generally the revocation will not be effective until your physician, other health care provider, or your agent has been provided a copy of the revocation, or is aware of your revocation. The revocation should be recorded in your medical chart if you are a patient in a health care institution.]
Names of institutions/individuals who have been provided a copy of this revocation:
! - !
! - !
! - !
! - !
! - !
! - !
! - !
Enter the name of a person or institution who will be be given a copy of the revocation or use the P.I. Manager to select and paste a record. If you are a patient in a health care institution, a copy of the revocation should be placed in your medical chart.
Enter an X to include the name of another person or institution who will be given a copy of the revocation.
Enter the name of another person or institution who will be given a copy of the revocation or use the P.I. Manager to select and paste a record.
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