Fill and Sign the Illinois Revocation Form 481379551

REVOCATION OF ILLINOIS STATUTORY SHORT FORM POWER OF ATTORNEY FOR HEALTH CARE I, ___________________________________________________________________, 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: _____________________________________________________