Revocation Of Power Of Attorney
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2REVOCATION OF POWER OF ATTORNEY
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]
(Acknowledgment by a person in New York State - Use Acknowledgment below if by a person outside New
York State)
State of New York, County of ________________________, ss:
On ______________________________________, before me, the undersigned, personally appeared
_____________________________________________, personally known to me or proved to me on the basis
of satisfactory evidence to be the individual(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 capacity(ies), and that by his/her/their
signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted,
executed the instrument.
(Signature and office of individual taking acknowledgement)
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