Gamitin ito kung ang tatanggap ng passport ninyo ay hindi magulang, asawa, kapatid, o anak (na

edad 18 or pataas).

REPUBLIC OF THE PHILIPPINES )

CITY OF _____________________ ) S. S.

SPECIAL POWER OF ATTORNEY

KNOW ALL MEN BY THESE PRESENTS:

That I, ________________________________, of legal age, Filipino, with address at

____________________________________________________, do hereby name, constitute and appoint
__________________________________________, of legal age, with residence at
_______________________________________________________________________________, as
my true and lawful attorney-in-fact, for me and in my name, place, and stead as if I am personally present,
to do and perform the following:

1. To receive my Philippine ePassport issued by the Department of Foreign Affairs, as evidenced by

the attached DFA Passport Application Receipt No. __________________ issued on
__________________; and
2. To do and perform other acts on my behalf, as may be deemed necessary, proper, or convenient
with reference to the immediately preceding item.

HEREBY GRANTING AND GIVING unto said attorney-in-fact full power and authority to do and
perform every requisite or necessary act to carry into effect the foregoing authority as fully to all intents and
purposes as I might or could lawfully do if personally present, and ratifying and conforming all that my said
attorney-in-fact shall lawfully do or cause to be done by virtue thereof.

Signed this _____ day of __________, ________ at _________________, Philippines.

______________________________________ ______________________________________

NAME AND SIGNATURE OF APPLICANT NAME AND SIGNATURE OF REPRESENTATIVE

Principal Attorney-in-Fact

Signed in the presence of:

______________________________________ ______________________________________

Witness Witness

ACKNOWLEDGMENT

BEFORE ME, a Notary Public, this _____ day of _______________ in ________________

personally appeared:

Name Government-issued ID Issuer/Expiry

1.
2.

All known to me and to me known to be the same persons who executed the foregoing instrument
and acknowledged to me that the same is their free act and voluntary deed.

The said instrument refers to a Special Power of Attorney (SPA) consisting of one (1) page,
including this page where the Acknowledgment is written and signed by the parties and witnesses.

IN WITNESS THEREOF, I have here unto set my hand and seal on the place, date, year first above
written.

Doc. No. _____________

Page No. ____________
Book No. ____________
Series of ________.