Revocation of Authorization to Communicate Information or of Power of Attorney
MR-69.R-V
Complete this form to revoke an authorization or power of attorney granted to a designated person.
Note
This form cannot be used to grant an authorization or power of attorney.
To grant an authorization or power of attorney, complete form MR-69-V, Authorization to Communicate Information or Power of Attorney.
2018-11 version
Follow the instructions below before clicking the Fillable PDF Document button at the bottom of the page.
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If you have already opened the fillable form, close it without saving it.
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Download Adobe Reader. If the software is already installed on your computer, go directly to step 4. If you don't want to install Adobe Reader, click the PDF Document button, print the form, complete it by hand and mail it to us.
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After downloading and installing Adobe Reader, close it.
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Place your cursor on the Fillable PDF Document button at the bottom of the page and right click to display a menu.
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Select Save link as.
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Save the document to your desktop or the folder of your choice. Do not open the document in the download screen that appears.
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Once the document is saved, right click on it to display a menu.
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Click Open with and select Adobe Reader.
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Complete and save the PDF.
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Follow the instructions to file the form.