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Fill and Sign the Revocation of Durable Power of Attorney for Health Care Indiana Form

Fill and Sign the Revocation of Durable Power of Attorney for Health Care Indiana Form

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REVOCATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE I,       , Declarant, having executed a Durable Power of Attorney for Healthcare on the       day of       , 20       , naming       my attorney-in-fact/agent, do hereby revoke that Durable Power of Attorney for Healthcare pursuant to its explicit provision that it may be revoked by me by written instrument signed by me and delivered to my attorney-in-fact/Agent. This is my written revocation of the above referenced Durable Power of Attorney for Healthcare and I am providing a copy of it to my attorney-in-fact/Agent. DATED this the       day of       , 20       . Signature of Declarant: __________________________________________________________ Printed Name of Declarant:       Address of Declarant:      

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