Fill and Sign the Wisconsin Legislature Chapter 155 Form

REVOCATION OF POWER OF ATTORNEY FOR HEALTH CARE (Wisconsin Statutes 155.40) I, ___________________________________________________________________, Declarant, executed a Power of Attorney For Health Care on the ________ day of ________________________, 20____, appointing an agent to make health care decisions for me if I were to be incapable of making those decisions. Wisconsin Statutes 155.40 provides that a Power of Attorney For Health Care can be revoked by me at any time by any of the following methods: 155.40(1)(a) (a) Canceling, defacing, obliterating, burning, tearing or otherwise destroying the power of attorney for health care instrument or directing another in the presence of the principal to so destroy the power of attorney for health care instrument. 155.40(1)(b) (b) Executing a statement, in writing, that is signed and dated by the principal, expressing the principal's intent to revoke the power of attorney for health care. 155.40(1)(c) (c) Verbally expressing the principal's intent to revoke the power of attorney for health care, in the presence of 2 witnesses. 155.40(1)(d) (d) Executing a subsequent power of attorney for health care instrument. This is my written revocation of my Power of Attorney For Health Care and is provided to all persons to whom I have provided a copy of my Power of Attorney For Health Care. DATED this the _________ day of ______________________________, 20____. Signature of Declarant: __________________________________________________________ Printed Name of Declarant: _______________________________________________________ Address of Declarant: ___________________________________________________________