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Fill and Sign the Revocation of Statutory Equivalent of Living Will or Declaration Illinois Form

Fill and Sign the Revocation of Statutory Equivalent of Living Will or Declaration Illinois Form

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REVOCATION OF DECLARATION (LIVING WILL) I, ___________________________________________________________________, Declarant, executed a Declaration (Living Will) on the ________ day of ________________________, 20____. 755 ILCS 35/5 provides that a declaration may be revoked at any time by the declarant, without regard to declarant'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 cancel; (2) By a written revocation of the declaration signed and dated by the declarant or person acting at the direction of the declarant; or (3) By a oral or any other expression of the intent to revoke the declaration, 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 Declaration (Living Will) and is provided to all persons to whom I have provided a copy of my Declaration (Living Will). DATED this the _________ day of ______________________________, 20____. Signature of Declarant: ____________________________________________________ Printed Name of Declarant: _________________________________________________ Address of Declarant: _____________________________________________________

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