POWER OF ATTORNEY REVOCATION

Reference is made to certain power of attorney granted by __________________________________ (Grantor) to __________________________________ (Attorney-in-Fact), and dated _________________, 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 seal this ____ day of_______________________________, 20______.



____________________________________
[Signature of Grantor]


____________________________________
[Printed or Typed Name of Grantor]


CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC

A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document, to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.


State of ____________________
County of ___________________

On __________________ before me, _________________________________ (here insert name and title of the officer), personally appeared _______________________________________, who 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.

I certify under PENALTY OF PERJURY under the laws of the State of ____________________ that the foregoing paragraph is true and correct.

WITNESS my hand and official seal.

 

_______________________________         (Seal)
Signature


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