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POWER OF ATTORNEY REVOCATION FORM
STATE OF ____________________ §
COUNTY OF ____________________ §
THE UNDERSIGNED HEREBY DECLARES THAT
I, ____________________, with a mailing address of ___________________________
_____________ City of ____________________, State ____________________
hereby revoke all Powers of Attorney executed prior to the ____ day of
____________________, 20___, made by me and appointing ____________________
as my Attorney-in-Fact, and ____________________ as my successor Attorney(s)-in-
Fact.
IN WITNESS WHEREOF, I have hereunto set my hand on this the ____ day of
____________________, 20___.
____________________
Signature of Principal
The foregoing Revocation was signed by ____________________ in our presence, and
we, at her request and in her presence, and in the presence of each other, each of us
being over the age of 18 years, have hereunto subscribed our names as Witnesses on
this the ____ day of ____________________, 20___.
__________________________ __________________________
Signature of Witness Signature of Witness
__________________________ __________________________
Street Address Street Address
__________________________ __________________________
City, State and Zip Code City, State and Zip Code
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STATE OF ____________________ §
COUNTY OF ____________________ §
BEFORE ME, the undersigned authority, on this day personally appeared
__________________________, who, having been duly sworn, states that he/she is
executing this Revocation in the presence of the Witness(es) as shown above and for
the purposes therein expressed.
SWORN TO, SUBSCRIBED AND ACKNOWLEDGED BEFORE ME by
__________________________ and by the said Witness(es)
__________________________, and __________________________, on this ____
day of ____________________, 20___.
__________________________
Notary Public
__________________________
Print Name
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