I, [list name of person revoking power of attorney - the "principal"], of [list address of principal], do hereby revoke the Power of Attorney dated [list date power of attorney was authorized], and recorded [if recorded, list place and date power of attorney was recorded], that was granted to [list name of person given power of attorney - the "agent"], of [list address of agent], and withdraw every power and authority conferred therein.
This instrument shall serve as notice to [list name of person given power of attorney] and to all interested persons that the above Power of Attorney hereby is null and void and of no further force or effect.
IN WITNESS WHEREOF, this instrument is executed under seal on the __________ day of _________________, 20_____.
_______________________________
[name and signature of person revoking power of attorney]
Signed, sealed and delivered
in the presence of:
____________________________
(Signature of witness
____________________________
(Signature of witness)
STATE OF _____________________
COUNTY OF ____________________
In _______________, on the _____________ day of ____________, 20 __, before me, a Notary Public in and for the above state and county, personally appeared [list name of person revoking power of attorney] , known to me or proved to be the person named in and who executed the foregoing instrument, and being first duly sworn, such person acknowledged that he or she executed said instrument for the purposes therein contained as his or her free and voluntary act and deed.
_______________________________
NOTARY PUBLIC
My Commission Expires: ________
(SEAL)