STATE OF OHIO	:
: ss
 	COUNTY :

REVOCATION OF POWER OF ATTORNEY

I, 	, whose permanent address is

 		, hereby revoke and render void the power of attorney I previously gave to	of
 	(city of residence), signed in 	.(year)

I further attest that a photostatic copy of this Revocation of Power of Attorney constitutes a "duplicate original" of said Revocation of Power of Attorney and thus is as effective as the original revocation itself.
Signed by me as an act of my free will under no legal or other duress this 	day of

 	, 20 	.

This revocation of Power of Attorney was sworn to and subscribed before me by

 	on 	, 20 	.

Notary Public