State of ______________
REVOCATION OF POWER OF ATTORNEY
WHEREAS, on ____________________, 20______, I, ________________________ [Principal], of
________________________________________ [Address], executed a: (Check one)
☐ Financial Power of Attorney
☐ Medical Power of Attorney
( ☐ recorded as Instrument No. _______________ in _______________________________ [County],
_________________ [State]) empowering ________________________ [Agent] to act as my true and
lawful attorney-in-fact to handle my financial affairs should I become incapacitated and unable to do so
myself (the “Power of Attorney”). 
NOW THEREFORE, I hereby give notice that I, being of sound mind, revoke and rescind the Power of
Attorney. As such, all power and authority granted to ________________________ [Agent] under the
Power of Attorney is hereby terminated.
IN WITNESS WHEREOF, I have signed my name below on this ______ day of _______________,
20______.
              Principal Signature                                        Principal Name
 
                                      WITNESS SIGNATURES
I hereby acknowledge that the foregoing Revocation of Power of Attorney was signed by
________________________ [Principal] in my presence. 
FIRST WITNESS:
First Witness’ Signature                          Date
First Witness’ Name
First Witness’ Address
City                                               State                        Zip Code
SECOND WITNESS:
Second Witness’ Signature                         Date
Second Witness’ Name
Second Witness’ Address
City                                               State                        Zip Code
  
                                        NOTARY ACKNOWLEDGEMENT OF PRINCIPAL
State of _________________                                 )
                                                            )          (Seal)
County of _________________                                 )
The foregoing instrument was acknowledged before me this ______ day of _______________,
20______, by the undersigned, ________________________ [Principal], who is personally known to me
or satisfactorily proven to me to be the person whose name is subscribed to the within instrument.
_____________________________________
Signature
_____________________________________
Notary Public
My Commission Expires: ________________