SPECIAL POWER OF ATTORNEY

KNOW ALL MEN BY THESE PRESENTS:

I, __________________________, of legal age, Filipino, and with residence at
______________________________, do hereby NAME, APPOINT, and
CONSTITUTE
______________________________, Filipino, of legal age, and with address at
_____________________, as my duly constituted ATTORNEY-IN-FACT, for me, in my name and
on my behalf, now and hereafter or until this power is expressly cancelled or revoked by
me in writing and by notarial act, to transact directly with ______________________ (the
Company) in connection with the submission of the required documents, signing of
documents as may be necessary to implement this authority and receipt and
endorsement of all my entitlement/benefits against Pre-Need Agreement No. __________ in
accordance with the Companys Alternative Payment Program (APP), as approved by
the Regional Trial Court of Makati, Branch 66, on July 10, 2015. This will authorize my
ATTORNEY-IN-FACT to sign all papers/documents including but not limited to the
Registration Form evidencing my participation in the AFP and to receive my Confirmation
of Participation in the AFP.
HEREBY GIVING AND GRANTING unto my said attorney-in-fact full power and
authority whatsoever requisite or proper to be done in or about the premises, as fully to
and/or for all intents and purposes as I might or could lawfully do if I were personally
present, with full powers of substitute and revocation, and HEREBY RATIFYING AND
CONFIRMING all that my said Attorney-in-Fact or his/her substitutes may do or cause to
done under and by virtue of these presents.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of

_____________ 2015, in Valenzuela City.

___________________

_________________

Attorney-in-Fact

Principal

SIGNED IN THE PRESENCE OF:

___________________

________________

ACKNOWLEDGMENT
Republic of the Philippines
City of Makati

]
] S.S.

BEFORE ME, this _____ of September 2015 in the City of Valenzuela, personally
appeared, _____________________, with his Identification Card as indicated below his name
and signature, known to me to be the same person who executed the foregoing Special
Power of Attorney and acknowledged to me that the same is his free and voluntary act
and deed.
IN WITNESS WHEREOF, I have hereunto set my hand and my notarial seal this
___ day of _____________ 2015 in the City of Valenzuela.
Doc. No. _____
Page No. _____
Book No. _____
Series of 2015

Notary Public