Witness Affidavit of Oral Revocation of Durable Health Care Power of Attorney 

The following person* , referred to as the Principal, was the maker and signatory of a Durable Health
Care Power of Attorney which was dated * , and which was executed by him or her for use in the
State of * . 


By this written affidavit, I, *  , the witness, hereby affirm that on the date of *  , I personally
witnessed the above-named  declarant make known to me, through verbal and/or non-verbal
methods, their clear and unmistakable intent to entirely revoke such Durable Health Care Power of
Attorney, or any other appointment or designation of a person to make any health care decisions on
his or her behalf. It is my belief that the above-named principal fully intended that all of the above-
mentioned documents no longer have any force or effect whatsoever.

Witness Acknowledgment

The declarant is personally known to me and I believe him or her to be of sound mind and under no
duress, fraud, or undue influence.

Witness Signature *   Date * 

Printed Name of Witness *