New York Revocation Power of Attorney Form

The New York revocation power of attorney form is a document that is utilized by a Principal for the specific purpose providing notice of revocation (removing permission to act)  of a powers document that had provided powers to an Agent to act on the behalf of the Principal for health care, finances, personal and/or real property taxes, vehicle or any other form of powers documents.

Completion and signature applied and delivery or service, to any agent or interested parties who may hold copy of this document will constitute immediate revocation and remain in compliance with proper notice as stated in any powers document.

How to Write 

Step 1 – Provision of Notice –

  • Enter the name of the Principal
  • Enter the date that the powers document was executed
  • Enter the name(s) of the designated Agent(s)
  • AND
  • Enter the date of the signature (which will also be the date of revocation) in mm/dd/yyyy format
  • Principal’s signature

Step 2 – List of Those Receiving Notice –

  • Enter the names of all Agents, family members, hospitals, facilities, institutions or any other interested parties who may require notification. This list may be placed in the space provided on the form.

Step 3 – Notarization –

As the Principal provides signature before the Notary Public, the Notary will then complete this section of the document in acknowledgement

Step 4 – Affidavit of Service  – Provide:

  • Select the method in which the Principal would choose to provide delivery/service to the Agent(s)
  • If more than one type of service is checked, provide which form of service next to each name

The Notary shall witness this section and indicate their witness by entering the date the section was sworn and by the Notary’s own signature

Step 5 – Revocation of Power –

  • Enter the date of the service of a copy of the revocation
  • Provide Signature
  • Printed name