I, [NAME OF PERSON WHO GRANTED POWER OF ATTORNEY (PRINCIPAL)], of [RESIDENCE OF PERSON WHO GRANTED POWER OF ATTORNEY], by written instrument dated [DATE OF POWER OF ATTORNEY], appointed [AGENT'S NAME] of [RESIDENCE OF AGENT], my Attorney-in-Fact for the purposes and with powers therein set forth, a copy of which is attached hereto as Exhibit "A".

I do hereby revoke the above-described Power of Attorney, and all power and authority thereby
given, or intended to be given, to [AGENT'S NAME], effective [DATE].

IN WITNESS WHEREOF, I have executed this Power of Attorney on this ____ day of _________, 200__.

 

                                                                                   
SIGNATURE OF PRINCIPAL


                                                                                   
PRINTED NAME OF PRINCIPAL
 

Witness Signature:___________________________________

Name:_____________________________________________

Address:___________________________________________

Witness Signature:___________________________________

Name:_____________________________________________

Address:___________________________________________

(This area for notary seal.)

EXHIBIT A
(Attach the Power of Attorney being revoked here.)

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