Fill and Sign the Revocation of Anatomical Gift Donation District of Columbia Form

REVOCATION OF ANATOMICAL GIFT I, __________________________________ , Declarant, having made an anatomical gift by virtue of that document of gift dated the _________ day of __________________________________ , 20 _________ . do hereby revoke such gift pursuant District of Columbia Code 7-1531.05 . , which provides that an anatomical gift may be revoked as follows: (a) Subject to § 7-1531.07, a donor or other person authorized to make an anatomical gift under § 7-1531.03 may amend or revoke an anatomical gift by: (1) A record signed by: (A) The donor; (B) The other person; or (C) Subject to subsection (b) of this section, another individual acting at the direction of the donor or the other person if the donor or other person is physically unable to sign; or (2) A later-executed document of gift, including a driver's license or identification card, that amends or revokes a previous anatomical gift or portion of an anatomical gift, either expressly or by inconsistency. (b) A record signed pursuant to subsection (a)(1)(C) of this section shall: (1) Be witnessed by at least 2 adults, at least one of whom is a disinterested witness, who have signed at the request of the donor or the other person; and (2) State that it has been signed and witnessed as provided in paragraph (1) of this subsection. (c) Subject to § 7-1531.07, a donor or other person authorized to make an anatomical gift under § 7-1531.03 may revoke an anatomical gift by the destruction or cancellation of the document of gift, or the portion of the document of gift used to make the gift, with the intent to revoke the gift. (d) A donor may amend or revoke an anatomical gift that was not made in a will by any form of communication during a terminal illness or injury addressed to at least 2 adults, at least one of whom is a disinterested witness. (e) A donor who makes an anatomical gift in a will may amend or revoke the gift in the manner provided for amendment or revocation of wills or as provided in subsection (a) of this section. This is my written revocation of my anatomical gift and is provided to all persons to whom I have provided a copy of my document of anatomical gift. DATED this the _________ day of __________________________________ , 20 _________ . Signature of Declarant: __________________________________________________________ Printed Name of Declarant: __________________________________ Address of Declarant: __________________________________ If the donor or other person is physically unable to sign a record, the record may be signed by another individual at the direction of the donor or other person and must: (1) be witnessed by at least two adults, at least one of whom is a disinterested witness, who have signed at the request of the donor or the other person; and (2) state that it has been signed and witnessed as provided in paragraph (1). WITNESS FORM The witnesses below declare that they are signing at the direction of the declarant after having witnessed the signature of the declarant, have no interest in the estate of the declarant under the laws of intestate succession or any will or the declarant or codicil thereto, and are not financially responsible for the declarant’s care. Witness Signature: ________________________________________________________ Witness Name:       Address:       Witness Signature: ________________________________________________________ Witness Name:       Address:       ACKNOWLEDGEMENT FORM District of Columbia Judicial District       The foregoing instrument was acknowledged before me this       ( date) by       . (name of person who acknowledged). Signature of Person Taking Acknowledgement: _______________________________________________ Title or Rank:       Serial Number, if any: