Fill and Sign the Tennessee Revocation Form

REVOCATION OF POWER OF ATTORNEY FOR CARE OF A MINOR CHILD As provided for in T.C.A. § 34-6-301 et seq., revocation of any previously executed Power of Attorney for Care of a Minor Child must be in writing. Properly executed, this form meets all requirements of T.C.A. § 34-6-301 et seq. to properly revoke said Power of Attorney for Care of a Minor Child. Please note, however, that use of this form is recommended, but not required to revoke a previously executed Power of Attorney for Care of a Minor Child. Part I : To be filled out and/or initialed by parent(s). 1. Minor Child’s Name       2. Mother/Legal Guardian’s Name & Address                   3. Father/Legal Guardian’s Name & Address                   4. Caregiver’s Name & Address                   Part II : To be filled out by the parent(s). I,       , hereby revoke the Power of Attorney for are of a Name of Parent(s) Minor Child for the child listed above in Part I, which was previously executed on 2       and give to       to act as said minor child’s Date Name of Caregiver Caregiver. All rights, power, and authority previously granted to said Caregiver pursuant to said Power of Attorney for Care of a Minor Child are hereby revoked, effective immediately. I understand that I must provide a copy of the Revocation to any health care provider and/or school that previously received a copy of the Power of Attorney. IN WITNESS WHEREOF, I/We sign this Revocation of Power of Attorney for care of a Minor Child and declare under penalty of perjury under the laws of the State of Tennessee that the foregoing is true and correct. STATE OF TENNESSEE ) COUNTY OF       )       Date:       Mother/Legal Guardian The Mother/Legal Guardian,       , personally appeared before me this       day of       , 20    . ________________________________ NOTARY PUBLIC My commission expires: __________________ STATE OF TENNESSEE ) COUNTY OF       )       Date:       Father/Legal Guardian The Father/Legal Guardian,       , personally appeared before me this       day of       , 20    . ________________________________ NOTARY PUBLIC My commission expires: __________________ 2