Philippine Statistics Authority

Samar Provincial Statistical Office

Civil Registry System (CRS) – Catbalogan Outlet
City of Catbalogan

Sir/Madam:

This is to authorize ______________________ of legal age, with residence address at

(Name of the person being authorized)
___________________________________, to request and issued with the PSA copy/ies of the
(Address of the person being authorized)
______________________________________ of __________________________, who is my
(Type of document) (Complete name of the document owner)
__________________________ for reason that I cannot transact personally in your office
(Relationship to the person authorizing)
because of the following reason/s: _____________________________________________.
(Reason/s)

I am attesting that this authorization letter including the personal information herein
mentioned are freely given by me being the _____________________ of the document owner.
(Relationship to the document owner)

I likewise give assurance that this is not to be used to commit deceit or fraud against any
party.

The following are the personal information and complete details of the document:

Complete Name : ___________________________________

Date of event : ___________________________________
Parents Name : ___________________________________
Purpose : ___________________________________
Number of copy/ies : ___________________________________

Signed this _____ day of ____________, at _____________________, Philippines.

Very truly yours,

__________________________
(Name and Signature)

Valid ID and Nos.:

Person who gave the authority : ___________________

Person authorized : ___________________