Fillable Printable Revocation of Power of Attorney for Care of a Minor Child - Tennessee

Revocation of Power of Attorney for Care of a Minor Child - Tennessee

POA Minor Revocation

REVOCATION OF POWER OF ATTORNEY FOR CARE OF A MINOR CHILD

As provided for in T.C.A. § 34-6-301 et. seq., revocation of any previously executed

Power of Attorney for Care of a Minor Child must be in writing. Properly executed, this

form meets all requirements of T.C.A. §34-6-301 et. seq. to properly revoke said Power

of Attorney for Care of a Minor Child. Please note, however, that use of this form is

recommended, but not required to revoke a previously ex ecuted Power of Attorney for

Care of a Minor Child.

Part I: To be filled out by parent(s) of m inor child:

1. Minor Child’s Name ________________________________________________

2. Mother/Legal Guardian’s Name & Address ______________________________

______________________________

3. Father/Legal Guardian’s Name & Address ______________________________

______________________________

4. Caregiver’s Name & Address ______________________________

______________________________

Part II: To be filled out by the parent(s).

, hereby revoke the Power of Attorney for Care of a

Name of Parent(s)

Minor Child for the child listed above in Part I, which was previously executed on

and given to to act said minor child’s

Date Name of Caregiver

Caregiver. All rights, power, and authority previously granted to said Caregiver pursuant

to said Power of Attorney for Care of a Minor Child are hereby revoked, effective

immediately. I understand that I must provide a copy of this Revocation to any health

care provider and/or school that previously received a copy of the Power of Attorney.

POA Minor Revocation

IN WITNESS WHEREOF, I/We sign this Revocation of Power of Attorney for Care of a

Minor Child and declare under penalty of perjury under the laws of the State of

Tennessee that the foregoing is true and correct.

STATE OF TENNESSEE )

COUNTY OF __________ )

______________________________ Date: ______________

Mother/Legal Guardian

The Mother/Legal Guardian, ______________________, personally appeared

before me this _____ day of ____________, 20___.

______________________________

NOTARY PUBLIC

My commission expires:

___________________

STATE OF TENNESSEE )

COUNTY OF __________ )

______________________________ Date: ______________

Father/Legal Guardian

The Father/Legal Guardian, ______________________, personally appeared

before me this _____ day of ____________, 20___.

______________________________

NOTARY PUBLIC

My commission expires:

___________________