I, [NAME], a shareholder of [CORPORATION'S NAME], a [STATE] corporation ("Corporation"), do hereby revoke and annul a certain proxy dated [DATE], previously given by me to [PROXY'S NAME] and also any all proxies or powers of attorney previously given by me to the extent that such proxy or power of attorney may authorize or empower any person or person's to vote in my name, or act for me in any way or manner whatsoever at any meeting or meeting of the shareholders of the Corporation, or to give consent of any kind or type to any shareholder action of the Corporation.

IN WITNESS WHEREOF, I have executed this revocation of proxy on [DATE].

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Shareholder

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