Fill and Sign the Power Attorney Revoked Form

AFFIDAVIT OF PRINCIPAL THAT POWER OF ATTORNEY REMAINS IN FULL FORCE STATE OF ____________________ COUNTY OF __________________ PERSONALLY appeared before me, __________________________________, hereinafter “Principal”, who being duly sworn by me states upon his or her oath and personal knowledge the following: 1. Principal resides in ___________________ County, ___________________. The Principal signed a written Power of Attorney on _______________________________, 20____, appointing _________________________ as his/her attorney-in-fact, hereinafter “Agent”. (A true copy of the power of attorney is attached hereto and incorporated herein.) 2. As Principal I hereby certify that the Power of Attorney referenced above remains in full force and has not been revoked, amended or cancelled by me, or by operation of law. 3. Since the date of execution of the Power of Attorney, all actions of my Agent pursuant to the power of attorney are fully recognized by me as binding. 4. My Agent remains empowered to act pursuant to the power of attorney and said agent has not been removed as my attorney-in-fact. DATED this the ________ day of _______________, 20_____. Principal _________________________________ ___________________________________ Witness Signature Pint Name: ________________________ Print Name: _________________________ __________________________________ Witness Print Name: ________________________ Sworn to and subscribed before me on this the ________ day of _____________________, 20____. _____________________________ Notary Public My Commission Expires:________________________