Kansas Power Of Attorney Revocation Form
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1KANSAS POWER OF ATTORNEY REVOCATION FORM
Any power of attorney made by _______________________ (Referred to as the "Principal")
that was previously made is hereby REVOKED.
Including but not limited to the form signed on _________________ with the Principal's
agent being _______________________.
EXECUTION
Executed this ____________, at _________________________, Kansas.
________________________ Principal.
This document must be: (1) Witnessed by two individuals of lawful age who are not the
agent, not related to the principal by blood, marriage or adoption, not entitled to any portion of
principal's estate and not financially responsible for principal's health care; OR (2) acknowledged
by a notary public.
______________________________ __________________________________
Witness
Witness
______________________________ __________________________________
Address
Address
(OR)
STATE OF ________________________)
SS.
COUNTY OF _______________________)
This instrument was acknowledged before me on _____________ by __________________.
__________________________________ (Signature of notary public)
(Seal, if any)
My appointment expires:__________________________
Copies
History: L. 1989, ch. 181, § 8; July 1.
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