Date: February 14, 2024

To the PSA representatives:

This is to authorize Ms. Regina Castro to secure one copy of my birth certificate with the
following details:

Complete Name: Reynaldo Cayanan Sampanga

Birthdate: October 26, 1947
Place of Birth: Mexico, Pampanga
Complete Name of Father: Teofilo Tumang Sampanga
Complete Maiden Name of Mother: Elena Meneses Cayanan

Purpose of the request: Visa

Thank you for your kind consideration.

Reynaldo C. Sampanga
Signature over printed name of the requester

* ID of the requester attached

Date: __________________

To the PSA representatives:

This is to authorize Ms. Rosibel Pineda to secure one copy of CENOMAR each for the following names:

Complete Name:
Birthdate:
Place of Birth:
Complete Name of Father:
Complete Maiden Name of Mother:

Complete Name:
Birthdate:
Place of Birth:
Complete Name of Father:
Complete Maiden Name of Mother:

Purpose of the request:______________________________________

Thank you for your kind consideration.

_________________________________________
Signature over printed name of the requester

* ID of the requester attached

Date: September 22, 2022

To the PSA representatives:

This is to authorize Ms. Jacqueline E. Cayanan to secure one copy of the death certificate of the person listed below:

Complete Name: Emelita Fausto Dizon

Date of Death: September 02, 2022
Place of Death: House at Sta. Ana, Pampanga

Purpose of the request:Benefit from Employment

Thank you for your kind consideration.

Josephine Dizon Guiao

Signature over printed name of the requester

* ID of the requester attached

n listed below:
Date: __________________

To the PSA representatives:

This is to authorize Ms. Rosibel Pineda to secure one copy of Certificate of Marriage
of the couple named below:

Complete Name of Husband:

Birthdate:

Complete Name of Wife:

Birthdate:

Date of Marriage:
Place of Marriage:

Purpose of the request:______________________________________

Thank you for your kind consideration.

_________________________________________
Signature over printed name of the requester

* ID of the requester attached