Fillable Printable Revocation of Durable Power of Attorney
Fillable Printable Revocation of Durable Power of Attorney
Revocation of Durable Power of Attorney
REVOCATION OF DURABLE POWER OF ATTORNEY
PLEAST TAKE NOTICE that on the day of ,
did duly make and appoint
PLEASE TAKE FURTHER NOTICE that
has revoked, voided and annulled the said Durable Power of Attorney and all powers and
authority given to are hereby voided and annulled.
IN WITNESS WHEREOF, hereto set forth
this day of
________________________________
(insert name and address of donor of Power)
(insert name and address of donee of Power)
(insert name of donor of Power)
(insert name of donee of Power)
(insert name of donor of Power) (has) (have)
ACKNOWLEDGEMENT TAKEN IN NEW YORK STATE
State of New York, County of , ss:
On the day of in the year ,
before me, the undersigned, personally appeared
,
personally known to me or proved to me on the basis of satisfactory
evidence to be the individual(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 capacity(ies), and that by
his/her/their signature(s) on the instrument, the individual(s), or the
person upon behalf of which the individual(s) acted, executed the
instrument.
ACKNOWLEDGEMENT BY SUBSCRIBING WITNESS
TAKEN IN NEW YORK STATE
State of New York, County of , ss:
On the day of in the year ,
before me, the undersigned, a Notary Public in and for said State,
personally appeared
,
the subscribing witness to the foregoing instrument, with whom I am
personally acquainted, who, being by me duly sworn, did depose and
say that he/she/they reside(s) in
(if the place of residence is in a city, include the street and street number if any, thereof);
that he/she/they know(s)
to be the individual described in and who executed the foregoing
instrument; that said subscribing witness was present and saw said
execute the same; and that said witness at the same time subscribed
his/her/their name(s) as a witness thereto
ACKNOWLEDGEMENT TAKEN IN NEW YORK STATE
State of New York, County of , ss:
On the day of in the year ,
before me, the undersigned, personally appeared
,
personally known to me or proved to me on the basis of satisfactory
evidence to be the individual(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 capacity(ies), and that by
his/her/their signature(s) on the instrument, the individual(s), or the
person upon behalf of which the individual(s) acted, executed the
instrument.
ACKNOWLEDGEMENT TAKEN OUTSIDE NEW YORK
STATE
*State of , County of , ss:
*(Or insert District of Columbia, Territory, Possession or Foreign County)
On the day of in the year ,
before me, the undersigned, personally appeared
,
personally known to me or proved to me on the basis of satisfactory
evidence to be the individual(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 capacity(ies), that by his/her/their
signature(s) on the instrument, the individual(s) or the person upon
behalf of which the individual(s) acted, executed the instrument, and
that such individual make such appearance before the undersigned in
the
(add the city or political subdivision and the state or country or other
place the acknowledgement was taken).
Title No.
TO
SECTION:
BLOCK:
LOT:
COUNTY OR TOWN
:
RETURN BY MAIL TO:
DISTRIBUTED BY
The Judicial Title Insurance Agency LLC
800-281-TITLE (8485) FAX: 800-FAX-9396
2004
