WHEREAS, on Enter date of delivery, Enter party revoking acceptance received delivery of the following described goods from Enter name of party providing faulty goods:

Enter description of the goods

and, WHEREAS, the goods so described were non-conforming to the contract because of:

Enter the reason that the goods were defective

and, WHEREAS, on Enter date of demand for adequate assurance, a demand for adequate assurance was made to Enter name of party providing faulty goods,

and Enter party revoking acceptance asserts pursuant to Article 2 of the Uniform Commercial Code of the state of Enter state where delivery took place a lien on the goods for damages caused by the non-conformity.

Therefore, Enter party revoking acceptance revokes its acceptance of the goods.

Dated: _______________________________

________________________________________________

Enter party revoking acceptance by an authorized officer