I, _________(1)____________, of
__________(2)__________, by written instrument dated
________(3)____________, 19__(4)_, appointed
_____________(5)______________ of ____________(6)____, my attorney in
fact for the purposes and with powers therein set forth, a copy of which
is attached hereto as Exhibit "A".
Notice is hereby given that I have revoked, and do
hereby revoke, the above-described power of attorney, and all power and
authority thereby given, or intended to be given, to
____________(5)_______________.
Dated ____________(7)_____________, 19__(8)_.
_____________(9)_______________
STATE OF _______(10)____________
COUNTY OF ______(11)____________
BEFORE ME, the undersigned authority, on this
_(12)_ day of _______(13)________, 19_(14)_, personally appeared
___________(15)___________ to me well known to be the person described
in and who signed the Foregoing, and acknowledged to me that he executed
the same freely and voluntarily for the uses and purposes therein
expressed.
WITNESS my hand and official seal the date
aforesaid.
___________(16)________________
NOTARY PUBLIC
My Commission Expires:__(17)___
NOTICE
The information in this document is designed to
provide an outline that you can follow when formulating business or
personal plans. Due to the variances of many local, city, county and
state laws, we recommend that you seek professional legal counseling before
entering into any contract or agreement.
