REVOCATION OF POWER OF ATTORNEY

I, John Smith, of 123 Main Street, Oaktown, MI 12345, hereby revoke the Power of Attorney
dated 10/01/2012, under which Sally Jones was appointed to act on my behalf.
Dated ____________________, _____, at Oaktown, MI.

__________________________________
John Smith

Witness Signature:___________________________________
Name: Joe Sampson
City: Park City
State: Ohio

Witness Signature:___________________________________
Name: Jenny Bay
City: Chino
State: Illinois

STATE OF _______________, COUNTY OF GRANT, ss:
The foregoing instrument was acknowledged before me this _____ day of
____________________, ______ by John Smith, ________________________________, and
________________________________, who are personally known to me or who have produced
________________________________ as identification.

_________________________________
Signature of person taking acknowledgment
_________________________________
Name typed, printed, or stamped
_________________________________
Title or rank
_________________________________
Serial number (if applicable)

Copy delivered to:
Agent:
Address:

Sally Jones
456 Central Ave
Rockville, Nebraska 67890

This document was prepared by:
Name:
Address:

Jill Hull
8343 Market Road
Bellington, WA 75644

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