Fillable Printable Revocation of Durable Power of Attorney Form
Fillable Printable Revocation of Durable Power of Attorney Form
Revocation of Durable Power of Attorney Form
REVOCATION OF DURABLE POWER OF ATTORNEY
PLEAST TAKE NOTICE that on the day of , ,
(insert name and address of donor of Power)
did duly make and appoint
(insert name and address of donee of Power)
PLEASE TAKE FURTHER NOTICE that (insert name of donor of Power)
has revoked, voided and annulled the said Durable Power of Attorney and all powers and
authority given to (insert name of donee of Power) are hereby voided and annulled.
IN WITNESS WHEREOF, (insert name of donor of Power) (has) (have) hereto set
forth (his) (her)this day of , .
________________________________
ACKNOWLEDGEMENT TAKEN IN NEW YORK STATE
State of New York, County of , ss:
On the day of in the year , before me, the
undersigned, personally appeared , personally known to
me or proved to me on the basis of satisfactory evidence to be
the individual(s) whose name(s) is (are) subscribed to the
within instrument and acknowledged to me that he/she/they
executed the same in his/her/their capacity(ies), and that by
his/her/their signature(s) on the instrument, the individual(s), or
the person upon behalf of which the individual(s) acted,
executed the instrument.
ACKNOWLEDGEMENT BY SUBSCRIBING WITNESS
TAKEN IN NEW YORK STATE
State of New York, County of , ss:
On the day of in the year , before me, the
undersigned, a Notary Public in and for said State, personally
appeared , the subscribing witness to the foregoing
instrument, with whom I am personally acquainted, who, being
by me duly sworn, did depose and say that he/she/they
reside(s) in
(if the place of residence is in a city, include the street and street number if any,
thereof);
that he/she/they know(s)
to be the individual described in and who executed the
foregoing instrument; that said subscribing witness was
present and saw said
execute the same; and that said witness at the same time
subscribed his/her/their name(s) as a witness thereto
ACKNOWLEDGEMENT TAKEN IN NEW YORK STATE
State of New York, County of , ss:
On the day of in the year , before me, the
undersigned, personally appeared , personally known to
me or proved to me on the basis of satisfactory evidence to be
the individual(s) whose name(s) is (are) subscribed to the
within instrument and acknowledged to me that he/she/they
executed the same in his/her/their capacity(ies), and that by
his/her/their signature(s) on the instrument, the individual(s), or
the person upon behalf of which the individual(s) acted,
executed the instrument.
ACKNOWLEDGEMENT TAKEN OUTSIDE NEW YORK
STATE
*State of , County of , ss:
*(Or insert District of Columbia, Territory, Possession or
Foreign County)
On the day of in the year , before
me, the unders igned persona lly appeared
Personally known t o me or proved to me on the basis of
satisfactory evidence to be the individual(s) whose name(s) is
(are) subscribed to the within instrument and acknowledged to
me that he/she/they executed the same in his/her/their
capacity(ies), that by his/her/their signature( s) on the
instrument, the individu al(s) or the person upon behalf of which
the individual(s) acted, executed the instrument, and that such
individual make such appearance before the undersigned in
the
(add the city or political subdivision and the state or countr y or
other place the acknowledgement was taken).
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