Fill and Sign the Revocation Power Attorney 497321803 Form

REVOCATION OF DURABLE GENERAL POWER OF ATTORNEY I, ___________________________________________________________________, Declarant, having executed a Durable General 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 at any time. This is my written revocation of the above referenced Durable General Power of Attorney and I am providing a copy of it to my attorney-in-fact/Agent. DATED this the _________ day of ______________________________, 20____. Signature of Declarant: __________________________________________ Printed Name of Declarant: __________________________________________ Address of Declarant: __________________________________________ __________________________________________ ACKNOWLEDGEMENT State of New York County of __________________ On the ________ day of _______________________ in the year _________ before me, the undersigned, personally appeared _________________________________________________ _______________________________________________________, personally known to me or proved 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.)