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Revocation Form

I, _______________ (“Declarant”), of _____________________________ (Address), through my Power of Attorney dated __________________ (“Power of Attorney”) made and appointed ________________, my true and lawful attorney in fact for the purposes, and with the powers set forth in the document.  

I hereby give notice that I have revoked and canceled, and hereby do revoke and cancel, the Power of Attorney, and all powers and authority given, provided or implied therein to in that Power of Attorney.

In witness of this act, I have signed this Notice of Revocation of Power of Attorney on _________ (Date).

Revoker of Power of Attorney

On this _____________ (Date), before me, personally appeared known to be the person described in and who executed the foregoing instrument and acknowledged to me that                           they executed the same as their free act and deed.

Notary Public
Commission Expires on: