I, ________________________, of _______________________,
by written instrument dated _______________________,
20______, appointed ______________________________
of ___________________, my attorney in fact for the
purposes and with powers therein set forth, a copy
of which is attached hereto as Exhibit "A".
Notice is hereby given that I have revoked, and
do hereby revoke, the above-described power of attorney,
and all power and authority thereby given, or intended
to be given, to
______________________________.
Dated ____________________________, 19______.
_______________________________
STATE OF _______________________
COUNTY OF ______________________
BEFORE ME, the undersigned authority, on this ______
day of ___________________, 20______, personally appeared
__________________________ to me well known to be
the person described in and who signed the Foregoing,
and acknowledged to me that he executed the same freely
and voluntarily for the uses and purposes therein
expressed.
WITNESS my hand and official seal the date aforesaid.
_______________________________
NOTARY PUBLIC
My Commission Expires:_________
NOTICE
The information in this document is designed to
provide an outline that you can follow when formulating
business or personal plans. Due to the variances of
many local, city, county and state laws, we recommend
that you seek professional legal counseling before
entering into any contract or agreement.