Business Power of Attorney Revocation Form

1. Revoking Party Information

Full Name Title/Position Business Name Business Address

2. Agent Information

Name of Agent/Attorney-in-Fact Agent's Business/Organization (if applicable)

3. Power of Attorney Details

Original Power of Attorney Date Description of Authority Granted

4. Statement of Revocation

I hereby formally revoke the Power of Attorney described above and declare that all authority and powers granted to the above-named agent are withdrawn effective immediately.

Effective Date of Revocation

City/State

Signature of Revoking Party

Date

5. Witness/Notary (if required)

Witness/Notary Name

Witness/Notary Signature

Date