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Revocation Power Of Attorney For Care And Custody Of Child (Tennessee) POA-TN 101 - Legal Forms
| Revocation Power Of Attorney For Care And Custody Of Child (Tennessee) Form. This is a Legal Forms form and can be used in Health Care-Minors Power Of Attorney . |
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TENNESSEE - REVOCATION POWER OF ATTORNEY FOR CARE AND CUSTODY OF CHILD NOTE: Revocation of any previously executed Power of Attorney for Care of a Minor Child must be in writing. Grounds for Revocation: Pursuant to Tennessee Code Sec 34-6-305 - the power of attorney does not provide legal custody to the caregiver; provided, however, that, if at any time the parent or legal guardian disagrees with the decision of the caregiver or chooses to make any healthcare or educational decisions for the minor child, the parent must revoke the power of attorney and provide the health care provider and local education agency either written documentation of the revocation or a court order appointing a legal guardian or legal custodian. Part I: To be filled out by parent(s) of minor child: 1. Minor Child's Name 2. Mother/Legal Guardian's Name & Address 3. Father/Legal Guardian's Name & Address 4. Caregiver's Name & Address Part II: To be filled out by the parent(s). I, , (Name of Parent(s) hereby revoke the Power of Attorney for Care of a Minor Child for the child listed above in Part I, which was previously executed on (Date) and given to (Name of caregiver) to act as said minor child's Caregiver. All rights, power, and authority previously granted to said Caregiver pursuant to said Power of Attorney for Care of a Minor Child are hereby revoked, effective immediately. I understand that I must provide a copy of this Revocation to any health care provider and/or school that previously received a copy of the Power of Attorney. IN WITNESS WHEREOF, I/We sign this written Revocation of Power of Attorney for Care of a Minor Child and declare under penalty of perjury under the laws of the State of Tennessee that the foregoing is true and correct. STATE OF TENNESSEE COUNTY OF Father/Mother/Legal Guardian ________________________________________________________________________ STATE OF TENNESSEE COUNTY OF ) , personally , 20 . ) Date: The Father/Mother/Legal Guardian, appeared before me this day of NOTARY PUBLIC My commission expires: American LegalNet, Inc. © www.FormsWorkFlow.com
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