SPECIAL POWER OF ATTORNEY

KNOW ALL MEN BY THESE PRESENTS:

That I, _______________________, (status/nationality/, of legal age, with address at

_________________________________________________, do hereby, appoint, name and
constitute,__________________________, (status/nationality/, of legal age, with address
_________________________________________________ to be my true and lawful attorney-in-
fact, to do and execute all or any of the following acts, deeds and things, to wit:

1. To transact and deal with the Social Security System (SSS) and Home
Development Mutual Fund (Pag-IBIG) for and on my behalf regarding all matters
relative to the claims from SSS and Pag-IBIG, she is also empowered to sign and
execute any and all documents relative thereto;

2. “To pick-up, receive and encash for and on my behalf any and all checks from
SSS and Pag-IBIG payable to me as a beneficiary.

HEREBY GIVING AND GRANTING unto my said attorney-in-fact full power and authority to
do and perform all and every act and things whatsoever requisite or necessary to be done in and
about the premises, as fully to all intents and purposes as I might or could do if personally present;
and,

HEREBY RATIFYING AND CONFIRMING all that my said attorney shall lawfully do or
cause to be done by virtue of these presents.

IN WITNESS WHEREOF, I have hereunto affixed our signatures on this

____________________ at the ____________________.

Conforme:

______________________ _______________________
Principal Attorney-in-fact

SIGNED IN THE PRESENCE OF

____________________ ____________________

ACKNOWLEDGMENT
REPUBLIC OF THE PHILIPPINES)
)s.s.

BEFORE ME, a Notary Public for and in the _______________, this

____________________ personally appeared the following:

Name Competent Evidence of Identity Issued on/at

known to me and to me known to be the same persons who executed the foregoing Special Power
of Attorney consisting of one (1) page including this whereon the acknowledgment is written, and
acknowledge to me that the same is their free will and voluntary act and deed.

WITNESS MY HAND AND SEAL this _______________ in the __________________.

Doc. No. _____;

Page No._____;
Book No._____;
Series of _____;