Please use BLUE BALLPEN

Date:________________

To: Department of Social Welfare and Development

Field Office VII,Cebu City

Letter of Authority To Recieve

I,____________________________________________, ______ years old and resident of

(Name of Senior Citizens) (Age)

___________________________________________________________________ authorizes
(Street, Barangay, Municipality/City)

Mr./Ms. ______________________________________who is my __________________________

(Name of Authorized Representative) (Relationship To the Beneficiary)

whose specimen signature/thumbmark appears below to recieve on my behalf my monthly stipend

as Indigent Senior Citizen for the period ___________________________________________ in
(Months covered)
the total amount of ____________________________________________( Php__________ ).
(Amount in words)
I cannot claim my stipend because of the following reason:

Sick/Bedridden

PWD

Old Age

Others: _______________________
Respectfully yours,

__________________________________
Signature/ thumbmark of Beneficiary

OSCA ID No. _____________

(Attach 2 photocopies)

___________________________________________
(Name and Signature of Authorized Representative)

Address: ___________________________________
ID No.: __________________
(Attach 2 photocopies)

Noted:

________________________________
Name and Signature of OSCA Head/C/MSWDO

Note: Please submit 1 original copy and 1 photocopy of this form when claiming the social pension.
Please use BLUE ballpen & BLUE stamp pad