What is the Principal's name? Enter the name of the person who is revoking the power of attorney. Would you like to enter the Principal's mailing address at this time? Yes (recommended)No If you choose not to enter the mailing address at this time, blank lines will be added to the form to be filled in later. Principal's mailing address: Street Address Address Line 2 City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code When does this revocation go into effect? Who was appointed as the Agent in the ORIGINAL power of attorney? Enter the name of the person whose power of attorney is being revoked. Did the original power of attorney include an Alternate Agent? YesNo Name of Alternate Agent: When was the original power of attorney signed? What type of decisions will the Agent NO LONGER be able to make? FinancialMedicalMinor (Child)Motor VehicleReal EstateTax Would you like to attach a notary acknowledgement to this form? Yes (recommended)No Many states require that a notary public sign a power of attorney revocation. Will any other witnesses sign this revocation? Yes, one witnessYes, two witnessesNo Refer to your state's laws to determine whether any other individual must witness and sign your revocation. Next Save Save and finish later
