WHEREAS, on [date delivered], [party revoking acceptance] received delivery of the following described goods from [party providing faulty
goods]:

[describe goods]

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

[list defects]

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

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

Therefore, [party revoking acceptance] revokes its acceptance of the goods.

Dated: _______________________________

________________________________________________
[party revoking acceptance] by an authorized officer