KNOW ALL MEN BY THESE PRESENTS:
That the [General or Special] Power of Attorney executed by [name of principal]
_______________________________
and recorded in book , _________ at page ___________, of the records of
______________ County, State of ________, by ____________________
by which the undersigned [name of principal] ________________________ constituted
[name of attorney] __________________________ attorney for the purpose set forth in
said Power of Attorney, is hereby wholly revoked, canceled and annulled.
Dated: ____________________
Witnesses
_____________________________ 
__________________________
(Seal)
State of __________________ )
County of ________________ )
This day, before me, a Notary Public in said County, personally came ______________, and
_____________________, and acknowledged the signing of this document to be a voluntary
act.
IN WITNESS WHEREOF I have hereunto set my hand and official
seal.
My commission expires: __________________
___________________________
Notary Public