Fill and Sign the On the Day of in the Year Before Me the Form

REVOCATION POWER OF ATTORNEY: CARE AND CUSTODY OF CHILD OR CHILDREN I, ___________________________________________________________________________, Declarant, having executed a Power of Attorney: Care and Custody of Child or Children on the ________ day of _________________________________________, 20____, naming _______________________________________ ___________________________________ my attorney-in-fact/agent, do hereby revoke that Power of Attorney pursuant to its provision that it may be revoked by me in writing.This is my written revocation of the above referenced Power of Attorney and I am providing a copy of it to my attorney-in-fact/Agent.DATED this the _________ day of ______________________________, 20____.______________________________________________ ACKNOWLEDGEMENT State of New York County of __________________On the ________ day of _______________________ in the year _________ before me, the undersigned, personally appeared _________________________________________________ _______________________________________________________, personally known to me orproved 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.)