FLORIDA POWER OF ATTORNEY REVOCATION FORM
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]
Acknowledged:
________________________________
STATE OF ____________________
COUNTY OF ___________________
On__________________________before me,_____________________________ personally
appeared, personally known to me (or proved to me on the basis of satisfactory evidence) to be
the person(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 authorized capacity(ies), and that by
his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the
person(s) acted, executed the instrument. WITNESS my hand and official seal.
Signature: ____________________________
Affiant: ____Known ____Unknown
ID Produced ____________________