Revocable Proxy : Please fill out the following form. Please print your completed form if you would to have a copy for your records.
BE IT KNOWN, that the undersigned (Stakeholder's name) of (Stakeholder's address) being the owner of 1000 shares of voting common stock of (Corporation) does hereby grant to (Name of the person who is granted the proxy) a proxy to vote on my behalf 1000 shares of stock at any future general or special meeting of the stockholders of the Corporation. Said proxy-holder is entitled to attend said meetings on my behalf or vote said shares through mail proxy, all to the same extent as if I voted said shares personally, and may vote on any matter that may properly come before said stockholder meeting.
During the pendency of this proxy, all rights to vote said shares shall be held by the proxy-holder and shall not be voted by the Undersigned, provided the undersigned may revoke this proxy at any time, upon written notice of termination by certified mail, return receipt.
The proxy-holder shall be entitled to reimbursement for reasonable expenses incurred hereunder, but otherwise shall not be entitled to compensation for the services to be rendered.
This agreement shall be binding upon and inure to the benefit of the parties, their successors, assigns, and personal representatives.
Signed under seal this day of (date and year).
STATE OF :
COUNTY OF :
On _______________________ before me _________________________ personally appeared ___________________________ personally known to me (or 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 his/her/their 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.
Affiant : Known / Unknown :
ID Produced :
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