The Massachusetts Power of Attorney Revocation Form is a crucial document used to officially and legally nullify a previously granted power of attorney. This is often utilized when an individual, the principal, decides to retract the powers granted to their appointed agent.

This could be due to various reasons, such as a change of mind, mistrust, or simply a change in circumstances. Filling out this form with precision is vital because it has to meet legal standards to ensure it is binding and protects the rights and wishes of the principal.


Part I


By checking the appropriate box, you communicate the scope of the power of attorney you are revoking. This helps in clarifying which specific powers are being rescinded.


Step 1: Health Care Powers


This typically relates to decisions regarding medical care, treatments, and health-related issues. Your agent would have had the authority to make decisions on your behalf regarding your health.

Example: If you had a surgery planned and granted someone the authority to make health-related decisions for you but now wish to rescind it, you’d check this box.


Step 2: Financial Powers


If you’ve given someone the right to make financial decisions on your behalf, like managing your bank accounts, investments, or property matters, and wish to take that back, this is the box for you.

Example: You initially granted your sibling the ability to handle your financial investments. But now, you’ve decided to manage them yourself.


Step 3: Other


Some powers of attorney don’t fit neatly into the health or financial categories. If the power you granted is more specialized or different from the two main types, specify it here.

Example: Perhaps you allowed a friend to handle only your property rentals while you were abroad.


Step 4: Principal’s Name


This is where you, the principal, write your full name, verifying your identity and asserting your authority to revoke the powers.

Example: I, John David Smith,


Step 5: Document Title


Indicate the exact title of the power of attorney document you’re revoking. This aids in eliminating ambiguity and ensuring the correct document is being referenced.

Example: … of the document titled ‘Financial Power of Attorney for John David Smith’,


Step 6: Date


Specify the date when you initially granted the power of attorney. This provides a clear timeline and solidifies which document you’re referring to.

Example: … executed on the 5th of May, 2020


Step 7: Name


Mention the name of the primary agent and the alternate (if any). This clarifies who is being stripped of their granted powers.

Example: … which appointed Emily Watson as my agent and James Thompson as my alternate successor agent.



Step 8: Date



Indicate the date you are signing the revocation. It provides a record and makes it clear from when the revocation is effective.

Example: … was signed the 10th of August, 2023.


Step 9: Signature of Principal 


Place your signature here to authenticate the document.


Step 10: Print Name


Finally, print your name legibly underneath, ensuring clarity of identity.


Part II



This section is completed by a notary public. When you present this form to a notary, they’ll validate your identity, watch you sign, then add their details and seal to confirm the document’s authenticity.


Step 1: County 


The notary will fill in the name of the county.

This establishes the jurisdiction where the notarization occurs, ensuring local legal protocols are followed.


Step 2: Date


The notary completes this section with the exact day, month, and year when the signing of the document is being acknowledged.

It’s a timestamp, crucial for determining the exact day the document was verified, which can be essential for legal validity and archival purposes.


Step 3: Name of Notary Public


The notary will insert their name.

Identifying the notary by name is a declaration of the official who authenticated the document. It’s pivotal to ensure that a certified individual verifies the information.


Step 4: Principal’s Name


Here, the name of the person or persons whose signature(s) is/are being authenticated is filled in.

This specifies who presented themselves before the notary, emphasizing direct interaction and identity verification.

Example: Personally appeared John A. Doe…


Step 5: Witness my hand and official seal



The notary will affix their signature.

The notary’s signature and seal certify that the signer was indeed the person they claimed to be, and the signing was done in the notary’s presence.


Step 6: Print Name


The notary neatly prints their name.

A printed name complements the signature and aids in the legibility of the notary’s identity.

Example: Clara Johnson


Step 7: Expiration Date


The notary provides the exact date when their commission will expire.

This is to confirm the notary’s current active status and validate that they conducted the notarization during the effective period of their commission.

Example: My Commission Expires on 5th of June, 2025.






The Massachusetts Power of Attorney Revocation Form is a critical legal document that enables a principal to nullify powers previously granted to an agent.

It must be completed thoroughly, with clarity on the precise powers being revoked, verified identities, and notarization to meet legal standards. This revocation protects the principal’s rights and intentions if circumstances change after initially granting authority.

Following each step meticulously and consulting a legal professional when necessary helps ensure the form achieves its purpose of officially rescinding the specified power of attorney.

With the proper completion and filing of this form, individuals can take back control of decisions regarding their healthcare, finances, or other private matters.