Statutory Declaration of Revocation of Authorization

STATUTORY DECLARATION OF REVOCATION OF AUTHORIZATION

I, ______, of ______, in the Province of Ontario, SOLEMNLY DECLARE that:

1. I previously gave the following authorization or consent: ______, to ______, on or about ______.

2. I now revoke that authorization in full, effective ______.

3. From the effective date, ______ has no further authority to act under it, and it is of no further force or effect.

4. I have taken reasonable steps to give notice of this revocation, and I make this declaration for the following purpose: ______.

I make this solemn declaration conscientiously believing it to be true and knowing that it is of the same force and effect as if made under oath.

DECLARED before me at the ______________________ of ______________________, in the Province of Ontario, this ______ day of ______________, 20______.

_______________________________ _______________________________

A Commissioner for taking Affidavits Signature of Declarant