FORM FIVE -- This document revocates a Living Trust Agreement. 
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            REVOCATION OF A REVOCABLE LIVING TRUST AGREEMENT 
 
 
TO: ________________________________________, Trustee 
    (name) 
 
    ________________________________________ 
    (address) 
 
    ________________________________________ 
    (city and state) 
 
I, (name), of (address), City of (city), State of (state), as
grantor in a 
Revocable Living Trust Agreement dated (date), wherein you are
designated as 
trustee, do hereby revoke the powers and trusts created and
conferred by 
grantor in that Revocable Living Trust Agreement, pursuant to the
terms 
thereof. 
 
I hereby direct you, as trustee, to turn over and deliver to me all
property 
held by you subject to the terms and provisions of the Revocable
Living Trust 
Agreement, together with all accumulations of interest and income.

 
In Witness Whereof, I have executed this instrument on the (day)
day of 
(month), 19(year), at (city), (state). 
 
In the presence of: 
 
 
_________________________ 
Grantor 
 
_________________________       _________________________ 
Witness 1                       Witness 2 
 
 
Sworn to and subscribed before me this (day) day of (month),
19(year). 
 
 
My commission expires:          _________________________ 
                                Notary Public 
 
_________________________ 
Date 
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