The following statutory short form, when reproduced and used in the identical indicated words or in substantially the same or more similar than dissimilar formulation of words by means of printing, typing, writing, or other method of reproduction and use or when appropriately adapted to particular circumstances, shall be and constitute a statutory short form revocation of power of attorney and, when completed by deletion by line or other clear obliteration of each included provision desired and permitted to be deleted and made inoperative, by inclusion by printing, typing, writing, or other clear presentation of each provision not included but desired and permitted to be included and made operative, and by insertion by printing, typing, writing, or other clear presentation of all additional data and information required to be included and when effectuated by execution by or for the principal, by acknowledgment by or for the principal, and by delivery by or at the express direction of or on behalf of the principal to the agent of at least one so completed, executed, and acknowledged form, shall revoke and terminate an agency relationship under a revocation of power of attorney in accordance with the Nebraska Short Form Act. REVOCATION OF POWER OF ATTORNEY .........., a domicilary of .......... County, Nebraska, Principal, desiring and intending under the Nebraska Short Form Act to revoke a previously effectuated Power of Attorney heretofore granted to or to each of .li on ........, a ........ of or with an office in .......... County, Nebraska, and ........, a ........ of or with an office in .........., County, Nebraska, Agent, does hereby effective on ............., 19...., effectuate Total Revocation of such Power of Attorney dated on ............, 19.... . .li off \EXECUTED at ........., ......... County, Nebraska, on ........, 19.... . .tb 5 10 15 20 25 30 34 37 \\\\\\................ \\\\\\Principal STATE OF NEBRASKA ) ) ss COUNTY OF........ ) .mc \The foregoing instrument was acknowledged before me on ..........., 19...., by or for the Principal by.............. . \\\\\\\.................... \\\\\\\\\Notary Public