59-12-43. Statutory form--Revocation.
A document substantially in the following form may be used to create a statutory form revocation of power of attorney that has the meaning and effect prescribed by this chapter. The provisions of §§ 43-28-23 and 7-9-1 apply to any power of attorney that is to be recorded with the register of deeds.
SOUTH DAKOTA
STATUTORY FORM REVOCATION OF POWER OF ATTORNEY
IMPORTANT INFORMATION
This revocation of power of attorney revokes a previously executed power of attorney including any nominations of guardian or conservator made within that instrument. This revocation does not revoke any power of attorney authorizing the agent to make health-care decisions for you. You should immediately deliver copies of this revocation to any person, institution, or company
that has a copy of the original power of attorney.
REVOCATION OF POWER OF ATTORNEY
I ________________________________ previously executed a Statutory Form Power of
(Name of Principal)
Attorney with a date of ______________________, 2____ and named the following person as my agent:
Name of Agent: _________________________________
Agent's Address: _________________________________
Agent's Telephone Number: _________________________
I also named the following successor agent(s):
Name of Successor Agent: _____________________________
Successor Agent's Address: _____________________________
Successor Agent's Telephone Number: ______________________
Name of Second Successor Agent: ___________________________
Second Successor Agent's Address: _________________________
Second Successor Agent's Telephone Number: _________________
I now hereby revoke that Statutory Form Power of Attorney.
EFFECTIVE DATE
This revocation of power of attorney is effective immediately.
SIGNATURE AND ACKNOWLEDGMENT
____________________________________________ ______________, 2____
Your Signature Date
____________________________________________
Your Name Printed
____________________________________________
Your Address
____________________________________________
Your Telephone Number
State of ____________________________ )
)SS.
County of ___________________________)
This Statutory Form Revocation of Power of Attorney document was acknowledged before me on _____________________, 2_____ by ___________________________________.
(Date) (Name of Principal)
____________________________________________ (Seal)
Signature of Notary Public
My commission expires:
Source: SL 2020, ch 214, § 43.