Revocation of Proxy : Please fill out the following form. Please print your completed form if you would to have a copy for your records.
I, (Stakeholder's name), the holder of 1000 shares of common voting stock of (Corporation), having appointed (Name) to act as my proxy by a written proxy dated (date and year), 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 this, the day of (date and year). The original of this revocation shall be filed in the office of the Corporation, and the duplicate copy of this revocation shall be delivered by Certified Mail, Return Receipt Requested, to (NAME) the person named by me as my proxy in the revoked proxy agreement.
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 :
Affidavits Forms Index
Revocation of Proxy
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