PROXY FORM

KNOW ALL MEN BY THESE PRESENTS:

That I, the undersigned member of the Public Safety Savings and Loan
Association Inc. (PSSLAI), a Non-Stock and Non-Profit organization, do hereby
nominate, constitute and appoint PMGEN EMMANUEL LUIS D LICUP, Director,
Directorate for Comptrollership, as my true and lawful attorney-in-fact or PROXY to
represent me and vote on my behalf during the special meeting scheduled
on_____________________, specifically for the purpose of removing the Incumbent
Board of Trustees of PSSLAI except for Independent Trustees, election of new Board of
Trustees,and on any and all matters and things that may come up at the said meeting
and adjournment thereof, as fully to all intents and purposes as I might or could do
personally if present.
The power and authority hereby granted shall remain valid and effective unless
withdrawn/ revoked by the undersigned through a written notice delivered to the
Corporate Secretary before the date of the meeting or shall be deemed suspended and
inapplicable in case the undersigned personally attend the meeting.
IN WITNESS WHEREOF, the undersigned member has executed this Proxy
Form this ___day of ___________, 2021 at__________________________________.

___________________________________
Printed Name and Signature of the Member
PSSLAI Member No._________________
PNP ID No. ________________________

SIGNED IN THEPRESENCE OF:

___________________________ __________________________________
Witness Witness

ACKNOWLEDGMENT

Republic of the Philippines )

Tuguegarao City ) ss

BEFORE ME, a Notary Public in and for ________________________ this ____

day of ___________ 2021, personally appeared the above-named person who has
satisfactorily proven to me his/her identity through his/her identifying documents written
below his/her name and signature, that he/she is the same person who executed the
foregoing instrument, that he/she acknowledged to me that the same is his/her free and
voluntary act and deed.

                                                                                                      
Doc. No.___;
Page No.___;
Book No. ___;
Series of 2021.