REVOCATION OF PROXY

I, , the holder of shares of

common voting stock of (Corporation), having appointed
to act as my proxy by a written proxy dated
, (year), a copy of which is attached, do hereby revoke that
proxy.
IN WITNESS WHEREOF, I do hereby execute this revocation of proxy in duplicate on
this, the day of , (year). The original of this revocation shall
be filed in the office of the Corporation, and the duplicate copy
of this revocation shall be delivered by Certified Mail, Return Receipt Requested, to
, the person named by me as my proxy in the revoked
proxy agreement.
___________________________________
STATE OF
}
COUNTY OF
On before me, , personally appeared
, personally known to me (or
proved to me on the basis of satisfactory evidence) to be the person(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 authorized capacity(ies), and that by his/her/their signature(s) on the instrument
the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
WITNESS my hand and official seal.
Signature___________________________
Affiant _____Known _____Unknown
ID Produced________________________
(Seal)
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