Revocation Of Illinois Statutory Short Form Power Of Attorney For Health Care printable pdf download

Revocation Of Illinois Statutory Short Form Power Of Attorney For Health Care

REVOCATION OF

ILLINOIS STATUTORY SHORT FORM POWER OF

ATTORNEY FOR HEALTH CARE

___________________________________________________________________,

Declarant, executed a Short Form Power of Attorney for Health Care on the ________

day of ________________________, 20____.

755 ILCS 45/4-6 provides that a health care agency may be revoked by the principal at

any time, without regard to the principal's mental or physical condition, by any of the

following methods:

1. By being obliterated, burnt, torn or otherwise destroyed or defaced in a

manner indicating intention to revoke;

2. By a written revocation of the agency signed and dated by the principal or

person acting at the direction of the principal; or

3. By an oral or any other expression of the intent to revoke the agency in the

presence of a witness 18 years of age or older who signs and dates a writing

confirming that such expression of intent was made.

This is my written revocation as indicated above of my Short Form Power of Attorney for

Health Care and is provided to all persons to whom I have provided a copy of my that

power of attorney.

DATED this the _________ day of ______________________________, 20____.

Signature of Declarant: ____________________________________________________

Printed Name of Declarant: _________________________________________________

Address of Declarant: _____________________________________________________

Revocation Of Illinois Statutory Short Form Power Of Attorney For Health Care