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FLORIDA POWER OF ATTORNEY REVOCATION
Use of this form is for the power of attorney of:
☐ - Health Care Powers
☐ - Financial Powers
☐ - Other: ____________________________________________________
I, ________________________________, hereby immediately revoke those
portions covering decisions of the document titled ______________________, that
I previously executed on the ___ of _____________________________, 20___
which appointed ________________________________ as my agent and
________________________________ as my
alternate successor agent. I hereby
notify said agent(s) and any other interested persons and institutions that all
portions of said document are revoked.
This revocation takes effect immediately. A photocopy has the same effect as an
original.
This revocation was signed this ___ of ___________________________, 20___.
Signature of Principal _________________________
Print Name _________________________
NOTE: Provide copies to anyone who may have copies of the Power of Attorney
that is being revoked. Retain the original of this form in your personal papers.
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We, the witnesses, each do hereby declare in the presence of the principal that the
principal signed and executed this instrument in the presence of each of us, that
the principal signed it willingly, that each of us hereby signs this power of attorney
presence, and that, to the best of our knowledge, the principal is eighteen years of
age or over, of sound mind, and under no constraint or undue influence.
________________________________________
Witness’s Signature
________________________________________
Address
_________________________________________
Witness’s Signature
________________________________________
NOTARY ACKNOWLEDGMENT
[State of Florida
County of ________________]
The foregoing instrument was acknowledged before me by means of ☐ physical
presence or ☐ online notarization, this _____ (numeric date) day of __________
(month), ______ (year), by ________________ (name of person acknowledging).
(Seal)
________________________
Signature of Notary Public
Print, Type/Stamp Name of Notary
Personally known: _____________________
OR Produced Identification: ______________
Type of Identification Produced: ___________
