[IMPORTANT NOTES:  

A notary and two competent adult witnesses not related to you or to each other, and none of them the Agent(s) previously appointed, should be used at the time of executing this Revocation of Power of Attorney.
 
Use one Revocation of Power of Attorney form for each original Power of Attorney being revoked.
 
This Revocation of Power of Attorney should also be delivered to the primary and any alternate Agents appointed at the time the original Power of Attorney was executed; otherwise, your Agent(s) may not realize that the original Power of Attorney has been revoked and may continue to act on your behalf.

Likewise, you should record the Revocation of Power of Attorney with your local county clerk-recorder if the original Power of Attorney was recorded or if such Power of Attorney was used in connection with a real estate transaction or other transaction subject to recording.

If you have any questions about powers of attorney or do not understand this document, consult an attorney in your state for legal advice.

This page is for informational purposes only and is not part of the Revocation of Power of Attorney.  Be sure to complete the information in red in the form, fill in the blanks, delete any language that does not apply, and make sure that the document prints out in only black ink.  Complete the page numbers and initial at the bottom of each page.]

REVOCATION OF POWER OF ATTORNEY
			 
I, ___________________________________________________________,

an individual residing in the County of _______________________________, 

State of _______________________________, Zip code___________________, and the 

following street address:________________________________________________________,

by written instrument dated ____________, appointed _________________________________, 

an individual(s) residing in the County of _______________________________, 

State of _______________________________, Zip code___________________, and the 

following street address:________________________________________________________,

my Attorney-in-Fact for the purposes and with powers therein set forth, a copy of which is attached hereto as Exhibit "A".

I do hereby revoke the above-described Power of Attorney, and all power and authority thereby

given, or intended to be given, to______________________________________________, 

effective ________________.

IN WITNESS WHEREOF, 

I have executed this Power of Attorney on this ____ day of _________, 201___.

							
SIGNATURE OF PRINCIPAL

							
PRINTED NAME OF PRINCIPAL

Witness Signature:___________________________________

Name:_____________________________________________

Address:___________________________________________

Witness Signature:___________________________________

Name:_____________________________________________

Address:___________________________________________

======================    

(THIS AREA FOR NOTARY PUBLIC)

STATE OF ________________________________

COUNTY OF ______________________________

On _______________, before me, ___________________________________, a Notary Public, 

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.	    _________________________________________
	 						Signature of Notary Public

My commission expires: ______________		

(This area for notary seal.)

EXHIBIT A

(Attach the original or a certified copy of the Power of Attorney being revoked.)