The Pennsylvania Revocation of Power of Attorney Form is a crucial legal document that allows an individual to cancel or revoke a previously granted power of attorney.

This form is essential because it ensures that the principal (the person who granted the power) can maintain control over their affairs and make changes as circumstances evolve.

It serves as a protective measure, ensuring that the principal’s wishes are respected and that any previously granted powers are nullified when desired.

This form is not just a mere administrative task; it’s a safeguard for one’s rights and autonomy.


Part I


In this section, you’re given a clear choice regarding the specific domain for which you’re revoking power of attorney. This aims to provide clarity and specificity, ensuring that the revocation only applies to your intended area.


Step 1: Health Care Powers


Select this if you’re revoking the authority for someone to make healthcare decisions on your behalf.

This can encompass decisions like medical treatments or end-of-life choices.



Step 2: Financial Powers


This pertains to any financial decisions or transactions. By ticking this, you’re ensuring that the said individual will no longer have the authority to handle your financial matters.



Step 3: Other


Other specific powers might not be mentioned in the first two options. In such cases, you can manually specify what they are.


Step 4: Principal’s Name


This space is for the name of the person revoking the power of attorney, known as the principal. It identifies the individual who initially granted the power and is now taking it back.

By clearly stating the principal’s name, it ensures that there’s no ambiguity about who is revoking the power. This clarity is vital for legal documents to prevent potential misuse or misinterpretation.


John A. Doe


Step 5: Title of the Document Being Revoked



This field specifies which power of attorney document is being revoked. It ensures that only the intended document is nullified and not any other unrelated documents.

By providing the exact title of the document, it narrows down the scope of revocation, ensuring precision and accuracy in the process.


“Medical Power of Attorney for John A. Doe”



Step 6: Date of Original Power of Attorney Execution



This space is for the date when the original power of attorney was executed. It provides a temporal reference, ensuring the correct document is identified.

Referencing the exact date further pinpoints the specific document being revoked, especially if multiple powers of attorney were executed over time.


5th of January, 2020



Step 7: Name of the Agent



This is the name of the person who was granted the power of attorney. It ensures that the right individual is notified of the revocation.

Identifying the agent is crucial. It ensures that the person who was previously granted power knows they no longer have that authority.


Jane B. Smith



Step 8: Name of the Alternate Successor Agent



This is the name of the backup agent, in case the primary agent was unable or unwilling to act. It ensures that all parties involved are aware of the revocation.

Mentioning the alternate agent ensures that there’s no loophole or oversight. If the primary agent can’t act, the alternate shouldn’t assume they still have power either.

Robert C. Johnson



Step 9: Date of Revocation Signing



This is the date when the revocation is being executed. It provides a clear timestamp of when the power of attorney was officially revoked.

This date is vital as it marks the exact moment the previous powers cease to exist, ensuring no overlap or confusion regarding the agent’s authority.

12th of August, 2023



Step 10: Signature of Principal



The principal’s signature is a formal acknowledgment and agreement to the revocation. It’s a binding mark of consent.

A signature is a universally accepted mark of agreement. In this context, it signifies the principal’s genuine intent to revoke the power of attorney.

[John A. Doe’s Signature]



Step 11: Print Name of Principal



This is a clear, legible version of the principal’s name, ensuring no ambiguity arises from the signature.

Sometimes, signatures can be hard to decipher. By printing the name, it ensures clarity and easy identification.


John A. Doe


Part II



This section is for a notary public to verify the principal’s identity and confirm that they willingly signed the document. It adds an extra layer of authenticity and protection.

Notaries are impartial witnesses. Their acknowledgment ensures that the principal wasn’t under duress when signing and that the document is genuine.


[Notary’s Signature and Seal]





The Pennsylvania Revocation of Power of Attorney Form is more than just a piece of paper; it’s a testament to one’s right to autonomy and control over their affairs.

By understanding each field’s significance, you’re not just filling out a form; you’re taking a proactive step in safeguarding your rights and ensuring your wishes are respected.

Always remember the importance of precision and clarity when dealing with such documents, as they play a pivotal role in protecting your interests.