QUEENSLAND TITLES REGISTRY	REQUEST TO REGISTER POWER OF ATTORNEY/	FORM 16 Version 4

Land Title Act 1994 and Land Act 1994	REVOCATION OF POWER OF ATTORNEY	Page 1 of 1

Dealing Number	Lodger(Name, address, E-mail & phone number)	Lodger
OFFICE USE ONLY Privacy Statement Collection of information from this form is authorised by legislation and is used to maintain publicly searchable records. For more information see the Titles Queensland website.	Code
1. Principal (Donor) Given names	Surname/Company name and number
* and as Trustee/Responsible Entity for * jointly and/or severally *delete if not applicable
2. Attorney (Donee) Given names	Surname/Company name and number
*jointly and/or severally * delete if not applicable
3. Request It is requested that you register: *Power of Attorney produced with this request *Power of Attorney Clause no. ………. in Dealing no. *Power of Attorney Clause no. ………. in Document dated produced with this request *Power of Attorney Pursuant to Section (name of legislation) *the attached Revocation of Power of Attorney Dealing no. . *delete if not applicable
4. Execution / / Execution Date Applicant's or Solicitor's Signature Note: A Solicitor is required to print full name if signing on behalf of the Applicant