Indiana Power of Attorney Revocation Form should be used when you desire to terminate a power of attorney that you previously executed. This type of document can be used to revoke any type of POA you may have executed. In addition to executing a revocation, you must alert your agent and any institution that may rely on the POA that you have revoked it. Otherwise, they are not liable, if they do not know about the revocation, for continuing to rely on the POA.

How to Write

1 – Make Sure The Target Document Of Authority Is Handy And Open This Form

The information on the original Authority (being revoked) should be transcribed onto this form precisely as it is recorded on the power document. Thus before downloading the form on this page, make sure the original target document is available for reference.

2 – The Type Of Authority Being Revoked

The first three lines will each have a checkbox (“Health Care Powers,” “Financial Powers,” and “Other”). Check the box that best defines the Authority being revoked. If you check “Other” make sure to define the type of Authority being revoked on the blank line.

3 – Supplement The Required Language With The Requested Information

On the empty space between the word “I” and the term “hereby immediately revoke…,” enter the Full Name of the Principal who has issued the previous authority paperwork and revoking such paperwork with this form.

The next empty space must have the exact Title of the power document being revoked entered accurately.

Locate the words “…I previously executed on the,” then enter the Day, Month, and Year the target document was executed.

Next, it will be necessary to enter the Full Name of the Agent and the Successor Agent named in the document being revoked as the holder of Principal Power. This should be done on the blank spaces preceding the words “as my agent…” and “as my alternate successor agent” (respectively).

4 – Complete The Execution Of This Revocation

The Principal should enter the Date he or she is signing this document using the three spaces in the statement beginning with “This revocation was signed…”

Below the reported Signature Date, the Principal must Sign and Print his or her Name on the appropriately labeled blank lines (“Signature of Principal” and “Print Name”).

The Notary Public is the only entity who may notarize this document on the “Notary Acknowledgment” page.

If you still have the original, attach it to the revocation form and provide copies to your agent as well as to other institutions that may have your original power of attorney on file.