HLURB Case Form No.

05

Republic of the Philippines

Office of the President
HOUSING AND LAND USE REGULATORY BOARD
- - - - - - - - - - Regional Field Office

Complainant/s,

- versus - HLURB Case No.

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Respondent/s.
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SPECIAL POWER OF ATTORNEY

KNOW ALL MEN BY THESE PRESENTS:

I, , of legal age, Filipino, with residence a t - - - - - - - -

- - - - - - - - - - - - - - - - - - - - - - - ' d o hereby appoint, name and constitute
likewise of legal age, single/married, with residence at
- - - - - - - - - - - - - - - - ' who is related to me and/or is my next-of-kin, and is not a
lawyer, as my true and legal representative to act for and in my name and stead and to represent me
during the Mediation/Preliminary Conference on , to enter into amicable
settlement, to submit to alternative modes of dispute resolution and to make admissions or stipulations
of facts and documents without further consultation from me, for the reason that I have not physically
capable of attending due t o - - - - - - - - - - - - - - - - - - - - - - - - - - -

I hereby grant my representative full power and authority to execute and perform every act necessary to
render effective the power to compromise as though I myself have so performed it and hereby approving
all that he may do by virtue of these presents.

In witness whereof, I hereunto set my hand this _ _ _ _ _ day of _______ , 20___ , at

Complainant/Respondent Representative

Witness Witness

REPUBLIC OF THE PHILIPPINES )

_ _ _ _ _ _ _ _ _ _ _ _)S.S.

BEFORE ME, a Notary Public for and in , Philippines, personally

appeared , with issued at
on , known to me and to me known to be the same person who
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executed the foregoing special power of attorney and he/she acknowledged to me that the same is his/her
voluntary act and deed.

IN WITNESS WHEREOF, I have affixed my signature and seal on the date and place first above-
written.

Doc.No. _ __
Page No. _ __ Notary Public
Book No. _ __
Series of _ __