This a notice sent by a principal to an agent revoking the power of attorney that was
previously granted. In order for this notice to be valid, the principal must be of sound
mind when executing this notice. The original power of attorney agreement can be
attached under “Exhibit A” of this document. Additionally, this notice must be notarized
by a notary public to ensure the proper identification of the parties. This document
should be used by individual or entities that want to revoke a power of attorney.
NOTICE OF REVOCATION OF POWER OF ATTORNEY
I, _______________, [Instruction: insert name] of ____________________
[Instruction: insert address], by written instrument dated __________, 20____, appointed
_______________ [Instruction: insert name], of __________________ [Instruction: insert
address], as my attorney-in-fact for the purposes and with powers therein set forth, a copy of
which is attached hereto as Exhibit “A.” [Comment: user should a copy of the original
agreement as an exhibit to this Notice of Revocation]
Notice is hereby given that I have revoked, and do hereby revoke, the above-described
Power of Attorney, and all power and authority thereby given, or intended to be given, to
_______________ [Instruction: insert name].
Dated: __________, 20____.
STATE OF _________________ COUNTY OF _________________
BEFORE ME, the undersigned authority, on this _________________ day of
_________________, 20__, personally appeared _________________ to me well known to be
the person described in and who signed the foregoing, and acknowledged to me that he/she
executed the same freely and voluntarily for the uses and purposes therein expressed.
WITNESS my hand and official seal the date aforesaid.
_________________, NOTARY PUBLIC
My Commission Expires: _________________
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