Fill and Sign the Revocation Power Attorney 497317206 Form

REVOCATION OF HEALTH CARE POWER OF ATTORNEY I,       , Declarant, having executed a Health Care Power of Attorney on the       day of       , 20       , naming       my attorney-in-fact/agent to make serious and far reaching health care decisions for me. I hereby revoke that Health Care Power of Attorney pursuant to North Carolina General Statutes § 32A- 20 which provides that "[a] health care power of attorney may be revoked by the principal at any time, so long as the principal is capable of making and communicating health care decisions. The principal may exercise this right of revocation by executing and acknowledging an instrument of revocation, by executing and acknowledging a subsequent health care power of attorney, or in any other manner by which the principal is able to communicate an intent to revoke." This is my written revocation of the above referenced Health Care Power of Attorney 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:       STATE OF NORTH CAROLINA COUNTY OF       On this       day of       , 20       , personally appeared before me, the said named       to me known and known to me to be the person described in and who executed the foregoing instrument and he (or she) acknowledged that he (or she) executed the same and being duly sworn by me, made oath that the statements in the foregoing instrument are true. _______________________________________________ (Signature of Notary Public) My Commission Expires:       Notary Public (Official Seal)