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Power of Attorney Revocation

This form revokes assigned power of attorney. The form letter provided here is simply a sample of what the actual form letter looks like.


Reference is made to certain power of attorney granted by ____________________________ (Grantor)

to ____________________________ (Attorney-in-Fact),

and date ____________________________, 21______.

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 ____________________________, 21_______.




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.


Affiant ____ Known ____ Unknown

ID Produced____________________


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