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Revocation of Power of Attorney Form

1. Description of Power of Attorney. KNOW ALL MEN BY THESE PRESENTS, that I, [name], residing at [address], did by an instrument dated [date] constitute and appoint [name], residing at [address], my true and lawful Attorney-in-Fact for me to do any and all acts that I could do if personally present.

2. Revocation of Power of Attorney. BY THESE PRESENTS I revoke and make void the instrument described above and all power to act for me given be that instrument to [name].

[city]

[dated]

[signature]

[Acknowledgment]

Revocation of Power of Attorney Form

I, __________________, herewith:

revoke that certain power of attorney, dated _______, 20___, naming _______________ as my attorney in fact.

Dated: __________________________



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Witnesses:


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Notary:
My Commission Expires: