I, __________________, herewith:

revoke that certain power of attorney, dated _______, 20___, naming _______________ as my attorney in fact.

Dated: __________________________

____________________________________________

Witnesses:

____________________________________________

___________________________________________

___________________________________________
Notary:
My Commission Expires:

Revocation of Power of Attorney
Review List

This review list is provided to inform you about this document in question and assist you in its preparation. This is a simple revocation that can promptly revoke a Power of Attorney you have given out. As a practical matter, get all the copies of the earlier Power of Attorney back in your possession.

1. Make multiple copies. Be sure everyone that originally got the Power of Attorney being revoked gets a copy of this document.

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