make your free mental health care declaration and power of attorney revocation

i hereby witness this revocation and attest that:

(1) i personally know the maker of this revocation and believe the maker of this revocation to be of sound mind;

(2) to the best of my knowledge, at the time of the execution of this revocation, i:

(a) am not related to the maker of this revocation by blood or marriage;

(b) do not have any claim on the estate of the maker of this revocation;

(c) am not entitled to any portion of the estate of the maker of this revocation by any will or by operation of law; and

(d) am not a physician attending the maker of the revocation or a person employed by a physician attending the maker of this revocation.

i am not the declarant's spouse or heir at the time of witnessing this document.

we declare that we have attained the age of majority and that the declarant signed and executed the instrument as his/her revocation of and that he/she signed willingly, or directed another to sign for him/her, and that he/she executed it as his/her free and voluntary act for the purposes expressed; and that each of the witnesses saw the declarant sign or another sign for him/her at his/her direction and, in the presence of the declarant and in the presence of each other, signed the revocation of as witness and that to the best of his/her knowledge the declarant had reached the age of majority, was of sound mind and was under no constraint or undue influence.

i am not the declarant's spouse nor related to the declarant by blood or adoption at the time of witnessing this document.

i declare under penalty of perjury under the laws of wyoming that the person who signed or acknowledged this document is personally known to me to be the declarant, that the declarant signed or acknowledged this revocation of in my presence, that the declarant appears to be of sound mind and under no duress, fraud, or undue influence, that i am not the health care agent (attorney-in-fact) of declarant, and that i am not a treating health care provider, an employee of a treating health care provider, the operator of a community care facility, an employee of an operator of a community care facility, the operator of a residential care facility, nor an employee of an operator of a residential care facility. i further declare under penalty of perjury under the laws of wyoming that i am not related to the declarant by blood, marriage, or adoption, and, to the best of my knowledge, i am not entitled to any part of the estate of the declarant upon the death of the declarant under a will now existing or by operation of law.

statement of witnesses

i declare that who signed or acknowledged this document (the "principal") has identified himself or herself to me, that signed or acknowledged this document in my presence, that appears to be of sound mind and under no duress or undue influence. i am at least 18 years of age and not the agent of , related to by blood, marriage, or adoption, entitled to any portion of the estate of under a will or codicil or intestate succession laws or directly financially responsible for 's health care. i am not a provider of health or residential care, an employee of a provider of health or residential care, the operator of community care facility, or an employee of an operator of a health care facility.

state of kansas

county of ____________________

this instrument was acknowledged before me on _____ day of ____________________, _____, by .

________________________________________

notary public

(seal, if any)

my appointment expires: _________________________