This required section states that the person ("Declarant") who made a Living Will now intends to rescind or cancel ("revoke") the Living Will. Press [Ctrl+F1] for more information.
This required section contains the signature block for the Declarant. Press [Ctrl+F1] for more information.
This optional section provides the witness signature block. If a state requires witnesses, this block will be automatically included. Press [Ctrl+F1] for more information.
This required section lists the persons or institutions given a copy of the revocation. This will not be effective until the physician has been informed of the revocation. Press [Ctrl+F1] for more information.
Times New Roman
Revocation of Living Will
REVLIW
The Revocation of Living Will is a document under which a person revokes a Living Will by declaring that the document will no longer be effective.
Enter the Declarant's city or edit the information as desired.
Enter the Declarant's state. The Declarant is the person who made a Living Will and now intends to rescind or cancel ("revoke") the Living Will. Press [Ctrl+F1] for more information.
Enter the name of the person (the "Declarant") who made a Living Will and now intends to rescind or cancel ("revoke") the Living Will, or edit the information as desired. Use the P.I. Manager to select and paste a record.
RLW01
! Revocation Section (1 of 4)
[This document has some state specific portions. Enter the state where the Declarant currently resides: !.]
! [All states other than Mississippi.]
REVOCATION OF
[NAME OF LIVING WILL AS IT APPEARS ON THE DOCUMENT]
I, !, of
!, ! !,
! Country: , !,
! , SSN: !
hereby revoke my ! dated !. The power and authority granted to my physician or any health care provider is revoked and withdrawn and this document provides notice of such revocation.
! [Mississippi]
REVOCATION OF LIVING WILL DECLARATION
On !,
I, !, of
!, Mississippi !,
! (Social Security Number),
being of sound mind, revoke the declaration made on ! (date declaration made), regarding the manner in which I die.
Enter the Declarant's state. The Declarant is the person who made a Living Will and now intends to rescind or cancel ("revoke") the Living Will. Press [Ctrl+F1] for more information.
This revocation section is used for Declarants living in any state except Mississippi. The program automatically selects this if you indicated that your state of residence is not Mississippi.
Enter the title of the Living Will as it appears in the document that will be revoked. (The above title of this Revocation will be centered when previewed or printed.) (For example, "Declaration to Physicians", "Declaration of a Desire For a Natural Death" or "Living Will Declaration"). Press [Ctrl+F1] for more information.
Enter the name of the person (the "Declarant") who made a Living Will and now intends to rescind or cancel ("revoke") the Living Will, or edit the information as desired. Use the P.I. Manager to select and paste a record.
Enter the Declarant's street address or edit the information as desired.
Enter the Declarant's extended street address or edit the information as desired.
Enter the Declarant's city or edit the information as desired.
Enter the Declarant's zip/postal code or edit the information as desired.
Enter an X to include the Declarant's country, if outside the United States.
Enter the country or edit the information as desired.
Enter an X to include the Declarant's social security number. Many health care facilities file their records, including Living Wills, by the Declarant's social security number.
Enter the Declarant's social security number or edit the information as desired.
Using the format MM/DD/YYYY, enter the Living Will's date. This date is the date the Living Will was signed, and should be the same date that is shown on the Living Will.
This revocation section is used only for Declarants living in Mississippi. The program automatically selects this if you indicated that your state of residence is Mississippi.
Using the format MM/DD/YYYY, enter the revocation date or edit the information as desired.
Using the format MM/DD/YYYY, enter the date the declaration was made.
Mississippi
RLW02
! Signature Section (2 of 4)
! [All states other than Mississippi.]
Dated this _____ day of _______________, 19___, at
SIGNED ____________________________________________________
This required section contains the signature block for the Declarant. This is automatically selected if you indicated that your state of residence is not Mississippi. Press [Enter] to continue.
Enter the city in which the Revocation will be signed or edit the information as desired.
Enter the state in which the Revocation will be signed or edit the information as desired.
This required section contains the signature block for the Declarant. This is automatically selected if you indicated that your state of residence is Mississippi.
Mississippi
RLW03
! Optional Witness Signature Section (3 of 4)
! [Mississippi] I hereby witness this revocation and attest that:
(1) I personally know the maker of this revocation and believe the maker of this revocation to be of sound mind;
(2) To the best of my knowledge, at the time of the execution of this revocation, I:
(a) Am not related to the maker of this revocation by blood or marriage;
(b) Do not have any claim on the estate of the maker of this revocation;
(c) Am not entitled to any portion of the estate of the maker of this revocation by any will or by operation of law; and
(d) Am not a physician attending the maker of the revocation or a person employed by a physician attending the maker of this revocation.
! [New Hampshire] I am not the Principal's spouse or heir at the time of witnessing this document.
! [New Mexico] We declare that we have attained the age of majority and that the Declarant signed and executed the instrument as his/her Revocation of Living Will and that he/she signed willingly, or directed another to sign for him/her, and that he/she executed it as his/her free and voluntary act for the purposes expressed; and that each of the witnesses saw the Declarant sign or another sign for him/her at his/ her direction and, in the presence of the Declarant and in the presence of each other, signed the Revocation of Living Will as witness and that to the best of his/her knowledge the Declarant had reached the age of majority, was of sound mind and was under no constraint or undue influence.
! [Vermont] I am not the Principal's spouse nor related to the Principal by blood or adoption at the time of witnessing this document.
! [All other states - there is no additional text required other than the Witness signatures.]
This is an optional section in most states. This box is automatically checked if your state requires witnesses. If your state does not require witnesses, you may include witness information by entering an X in this box.
Mississippi requires two "disinterested" persons witness the signature of the Revocation. Note the limitations on who may serve as witnesses. The program automatically selects this option if you indicated that your state of residence is Mississippi. Press [Enter] to continue to the next state.
New Hampshire requires two "disinterested" persons witness the signature of the Revocation. Note the limitations on who may serve as witnesses. The program automatically selects this option if you indicated that your state of residence is New Hampshire. Press [Enter] to continue to the next state.
New Mexico requires at least one witness sign this Revocation. Note the limitations on who may serve as witnesses. The program automatically selects this option if you indicated that your state of residence is New Mexico. Press [Enter] to continue to the next state.
Vermont requires two "disinterested" persons witness the signature of the Revocation. Note the limitations on who may serve as witnesses. The program automatically selects this option if you indicated that your state of residence is Vermont. Press [Enter] to continue to the next state.
There is no additional text required for your state. The program automatically selects this option if you indicated that your state of residence is not New Hampshire, New Mexico, Mississippi or Vermont. Press [Enter] to move to the first witness field.
Enter the name of the witness or use the P.I. Manager to select and paste a record. A witness formalizes the document even if not required by your state. The following information regarding the name and address of the witness may be left blank and be completed when the document is signed.
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 name of the second witness 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.
Mississippi
New Hampshire
New Mexico
Vermont
Mississippi
New Hampshire
New Mexico
Vermont
RLW04
! Notification Section (4 of 4)
[Copies of this revocation should be given to anyone who has a copy of your living will. Generally the revocation will not be effective until your physician or other health care provider has been provided a copy of the 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:
! - !
! - !
! - !
! - !
! - !
! - !
! - !
! NOTE: This revocation should be filed with the Mississippi Bureau of Vital Statistics of the State Board of Health.
Enter the name of a person or institution who has been 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 has been given a copy of the Revocation.
Enter the name of a person or institution who has been given a copy of the Revocation or use the P.I. Manager to select and paste a record.
This special note applies to the state of Mississippi only. The program automatically selects this if you indicated that your state of residence is Mississippi.
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