Fill and Sign the Revocation of General Durable Power of Attorney Ohio Form

REVOCATION OF GENERAL POWER OF ATTORNEY I, ___________________________________________________________________, Declarant, having executed a General Durable Power of Attorney on the ________ day of ________________________, 20____, naming _______________________________________ ___________________________________ my attorney-in-fact/agent, do hereby revoke that Power of Attorney pursuant to its explicit provision that it may be revoked by me by written instrument signed by me and delivered to my attorney-in-fact/Agent. This is my written revocation of the above referenced General Durable Power of Attorney and I am providing a copy of it to my attorney-in-fact/Agent. Signed this _________ day of __________________________________________, 20________ __________________________________________ (Principal's Signature) __________________________________________ (Principal's Social Security Number) The principal has had an opportunity to read the above form and has signed and executed the above form in our presence as the free act and deed of the Principal. We, the undersigned, each being over 18 years of age, witness the principal's signature at the request and in the presence of the principal, and in the presence of each other, on the day and year above set out. Witnesses: _________________________________ Signature _________________________________ Name _________________________________ Address _________________________________ _________________________________ Signature _________________________________ Name _________________________________ Address _________________________________ CERTIFICATE OF ACKNOWLEDGMENT STATE OF OHIO COUNTY OF _____________________________ Personally appeared before me, a Notary Public in and for the County and State above named, _____________________________________________________________________________, personally known to me or who proved his/her identity to my satisfaction, who acknowledged that he/she signed the above and foregoing Power of Attorney. This is the _______ day of __________________________________________, 20_____. _______________________________________________ Notary Public My Commission expires: __________________________