Appointment Of Short-Term Guardian For Minor Child(Ren) And Durable Healthcare Power Of Attorney Page 5

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REVOCATION OF SHORT-TERM GUARDIANSHIP
I/We,
hereby
revoke
 the Appointment of Short-Term Guardian for Minor Child(ren) and Durable Healthcare
Power of Attorney dated the
day of
, 201
; or
 any and all Appointment of Short-Term Guardian for Minor Child(ren) and Durable Healthcare
Power of Attorney forms
with regard to
 all minor child(ren) listed therein, or
 the following named minor child(ren) only:
previously executed by me/us, effective as of
 immediately;
 the
day of
, 201
; or
 the occurrence of the following event(s) or condition(s), which were not previously specified in
the Appointment of Short-Term Guardian for Minor Child(ren) and Durable Healthcare Power of
Attorney dated the
day of
, 201
CUSTODIAL PARENT(S)/GUARDIAN(S):
Sign:
Sign:
Print Name:
Print Name:
Date Signed:
Date Signed:
After signing, provide copies of this Revocation to the short-term guardian(s) whose power are being
terminated and to any third parties known to be relying on the short-term guardian(s)’s powers
immediately.
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