Power of Attorney Revocation

POWER OF ATTORNEY REVOCATION

Reference is made to certain power of attorney granted by __________________________________ (Grantor) to __________________________________ (Attorney-in-Fact), and dated _________________, 20______.

This document acknowledges and constitutes notice that the Grantor hereby revokes, rescinds and terminates said power-of-attorney and all authority, rights and power thereto effective this date.


Signed under seal this ____ day of_______________________________, 20______.

____________________________________
[Signature of Grantor]

____________________________________
[Printed or Typed Name of Grantor]

CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC

State of ____________________
County of ___________________

On __________________ before me, _________________________________ (here insert name and title of the officer), personally appeared _______________________________________, who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of ____________________ that the foregoing paragraph is true and correct.

WITNESS my hand and official seal.

_______________________________         (Seal)
Signature