NOTICE OF
REVOCATION OF POWER OF ATTORNEY
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)___
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