Proxy Revocable

Company Letterhead

{{company_name}}

{{company_address}}

Phone: {{phone}}

Email: {{email}}

Website: {{website}}

Date

{{date}}

To Whom It May Concern

This serves as a formal notification of the revocation of a proxy previously granted.

Details of Proxy Being Revoked

I, {{principal_name}}, residing at {{principal_address}}, hereby revoke in its entirety the proxy granted to {{proxy_name}}, residing at {{proxy_address}}, on {{date_proxy_granted}}.

The aforementioned proxy granted authority for {{proxy_name}} to act on my behalf in matters relating to {{scope_of_proxy}}.

Reason for Revocation (Optional)

The reason for this revocation is: {{reason_for_revocation}}.

Effective Date of Revocation

This revocation is effective immediately upon the date of this document, {{effective_date_of_revocation}}.

Instructions for Affected Parties

All parties previously relying on the authority of the now-revoked proxy are hereby instructed to cease and desist from recognizing any actions taken by {{proxy_name}} on my behalf after the effective date of this revocation.

A copy of this revocation has been sent to {{affected_parties_list}}.

Indemnification (Optional)

I hereby agree to indemnify and hold harmless any third party who acts in good faith reliance upon this revocation.

Governing Law

This Revocation of Proxy shall be governed by and construed in accordance with the laws of {{country_of_governance}}.

Signature

___________________________

{{principal_name}}

{{principal_id_number}}

Dated: {{signature_date}}

Witness (Optional)

Witness Name: ___________________________

Witness Signature: ___________________________

Witness ID Number: ___________________________

Dated: {{witness_signature_date}}