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Revocation Of Proxy
REVOCATION OF PROXY
The undersigned, [Shareholder's Name], is the holder of [Number of Shares] shares of the common stock of [Corporation's Name], having appointed [Appointee's Name] to act as my proxy by a written proxy dated [Date], a copy of which is attached, do hereby revoke that proxy.
IN WITNESS WHEREOF, I do hereby execute this revocation of proxy in duplicate on [Date]. The original of this revocation shall be filed in the office of [Corporation's Name] Corporation, and the duplicate copy of this revocation shall be delivered by Certified Return Receipt mail, to the person named by me as my proxy in the revoked proxy agreement.
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Date: [Date]
Time: [Time]
[Jurisdiction]
STATE OF [State]
COUNTY OF [County]
On [Date] before me, [Person's Name] personally appeared and proved to me on the basis of satisfactory evidence to be the [person(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] authorized [capacity(ies)], and that by the [signature(s)] on the instrument the [person(s)], or the entity upon behalf of which the [person(s)] acted, executed the instrument.
WITNESS my hand and official seal.
Signatures
[Identification Produced]
Seal