Reference is made to certain power of attorney granted by _______________ (Grantor) to ____________________ (Attorney-in-Fact), on _____________, 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 sael this ______ day of __________________, 20___.
STATE OF )
COUNTY OF )
On before me, , personally appeared __________, personally known to me (or 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.
WITNESS my hand and official seal.
Affiant ____Known ____Unknown