1. IDENTIFY Principal and Attorney-in-Fact:
Principal: Name Address of Residence City State Zip Code D/O/B
Agent /Attorney-In-Fact: Name Address of Residence City State Zip Code D/O/B
2. REVOCATION by Principal:
I, of , city of , in (Principal’s printed name) (Principal’s Street Address)
the County of , State of , (Zip Code)
hereby revoke the Power of Attorney dated , 20 ,
given to, and empowering to act in my behalf as my true and lawful
(Name of Attorney-in-Fact)
Attorney in Fact to handle my affairs. I declare that all power and authority granted under said Power of Attorney is here by revoked and withdrawn, and Attorney in Fact no longer has the authority to act in my behalf in any matter.
______________________________ ________, 20
Principal Signature Date
3. SIGNATURE of WITNESS:
___________________________________________________ (Printed Name of Witness)
___________________________________________________ (Signature of Witness)
___________________________________________________ (Address of Witness)
___________________________________________________ (City, state & zip code of Witness)
4. NOTARIZATION:
STATE OF
COUNTY OF
Subscribed, sworn to or affirmed, and acknowledged before me by ____________________, the principal, and subscribed and sworn to or affirmed before me by ______________________________, witness, this ______ day of ____________.
(notary seal) Notary Public
