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

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

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REVOCATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE I, ___________________________________________________________________, Declarant, executed a Durable Power of Attorney for Health Care on the ________ day of ________________________, 20____, appointing ____________________________________ ______________________________________________ as my attorney in fact to make health care decisions for me. Ohio Revised Code § 1337.17 provides that I may revoke this Durable Power of Attorney for Health Care at any time and in any manner. This is my written revocation of my Durable Power of Attorney for Health Care and is provided to all persons to whom I have provided a copy of my Durable Power of Attorney, including the person I appointed as my attorney in fact. DATED this the _________ day of ______________________________, 20____. Signature of Declarant: ________________________________________________ Printed Name of Declarant: ________________________________________________ Address of Declarant: ________________________________________________ CERTIFICATE OF ACKNOWLEDGMENT STATE OF OHIO COUNTY OF _____________________________ Personally appeared before me, a Notary Public in and for the County and State above named, _____________________________________________________________________________, personally known to me or who proved his/her identity to my satisfaction, who acknowledged that he/she signed the above and foregoing Power of Attorney. This is the _______ day of __________________________________________, 20_____. _______________________________________________ Notary Public My Commission expires: __________________________

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