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LEGALDOCS - Revocation of Child Care Authorization Questionnaire

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Skip the following explanation and go directly to Questionnaire below:

A Revocation of Child Authorization is an instrument revoking the authorization granted to another person to make certain decisions on behalf of a minor child. This form requires you to describe the prior written child authorization which was granted, and then revokes that authorization for all purposes.

If you have granted a Child Authorization to a person who is acting as your agent, but now wish to revoke such power, you may use this form. If you want to draft another Child Authorization appointing a different agent or if you have not created a Child Authorization, you can use this Child Authorization.

To create a Revocation of Child Authorization, complete the Questionnaire below.


Please enter the following information about the person who is revoking the Child Authorization and the person who was to act as the agent.

Enter the name and address of the person revoking the Child Authorization (the "Parent/Guardian").


Street Address:



Enter the name and address of the person (the "Agent") whose authority, as the Agent under the Child Authorization, is being revoked. If you don't know the address, you can either leave the space blank, in which case the final document will provide for no address, or you can insert a line to mark a space where you can insert an address at a later time.


Complete Address:

(e.g., 8632 Stevenson Street Apt No. 891, Lakeside, California 93468).


The child or children affected by the Authorization are:

    Child 1:
    Child 2:
    Child 3:
    Child 4:

The Authorization being revoked was signed on this date: .
The Authorization being revoked was signed in the County of : County.
The Authorization being revoked was signed in the State of: .


Complete the following sentences if you know where and/or when this Revocation of Child Authorization will be signed, otherwise, blank spaces will be provided in lieu of the missing data for your convenience.

The date that this Revocation will be signed is: (e.g.,August 1, 2000).
The County that this Revocation will be signed is: County.
The State that this Revocation will be signed is: .

This completes the information input for your Revocation of Child Care Authorization. When you Send this Form, this program will prepare a Summary of the Revocation of Child Care Authorization for your review. Make sure that all facts stated in the Summary are correct in all respects.


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