I, _____________________, of ____________________, by written instrument dated ____________________, 200(x), appointed ___________________________ of ________________, 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 ___________________________.
Dated _________________________, 200(x).
____________________________
Notary:
STATE OF ______________________
COUNTY OF _____________________
BEFORE ME, the
undersigned authority,
on this ______ day of _______________, 200(x), personally appeared
______________________ 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.
___________________________
NOTARY PUBLIC
My Commission Expires:__________
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