02/2011
City/County of __________________________, State/Commonwealth of ______________________________
wish to revoke my durable power of attorney on file with the Richmond Retirement System.
I, _______________________________________, of ________________________________________________,
AddressFull Name
Notary Public:
PART C: NOTARY PUBLIC CERTIFICATION
Seal:
Notary Registration Number:
Filed By:Received By:
State of: City/County of:
RRS USE ONLY
Date
My commission expires:
The individual whose name is signed above appeared before me on _________________ , acknowledged before me
the signature to be his/her, and having been duly sworn by me, made an oath that the statements maid in the said
instrument are true.
Filed By:Received By:
To be completed by Notary or by other Court Official authorized to take acknowledgements:
REVOCATION OF RRS DURABLE
Signature
Phone Number:SSN:
PART A: REVOCATION STATEMENT
POWER OF ATTORNEY FORM
please type or print in ink
900 East Broad Street
Room 400
Richmond, VA 23219
RICHMOND RETIREMENT SYSTEM
www.richmondgov.com/retirement
Phone 804.646.5958
Fax 804.646.5299
