SPECIAL POWER OF ATTORNEY

KNOW ALL MEN BY THESE PRESENTS:

I, JUAN DELA CRUZ, of legal age, Filipino, married and presently residing at
Quezon City do hereby NAME, CONSTITUTE and APPOINT JUANA DELA
CRUZ, of legal age, Filipino, married and a resident of Quezon City, to be my true and
lawful attorney-in-fact, for me and in my name, place and stead, to do and perform the
following special powers, to wit:
1.

To represent me, process, claim and receive in my behalf

whatever/all/any benefit/s and financial assistance for disaster victims (e.g.
emergency shelter assistance from the DSWD under Ticket No. ______/
Payroll No. _____, etc.) that may be issued, given or released by any/all
offices/departments of the government in my favor as a victim of super typhoon
Yolanda;

2.

To claim and receive in my behalf any form of cash or check that may be
issued by the said respective government offices in connection to the said
transaction;

3.

To make, sign, execute and deliver contracts, documents, agreements and

other writing of whatsoever nature, kind and description, with all third
persons, concerns and entities, upon such terms and conditions acceptable to
my said attorney-in-fact which may be necessary to effect and complete the
said transaction/s;

HEREBY GIVING AND GRANTING unto said attorney-in-fact full power

and authority to do and perform any and every act and thing of whatever requisite and
necessary or power to be done in and about the premises as fully to all intents and
purposes as I might or could do if personally present and acting in person and
HEREBY RATIFYING AND CONFIRMING all that my said attorney-in-fact shall
lawfully do and cause to be done under and by virtue of these presents.
IN WITNESS WHEREOF, I have hereunto affixed my signature this
____________ at ___________, Philippines.
JUAN DELA CRUZ
Principal
ID No: ______________
Issued by: ___________
Acceptance:
JUANA DELA CRUZ
Attorney-in-Fact
SIGNED IN THE PRESENCE OF: _______________

________________

REPUBLIC OF THE PHILIPPINES)

PROVINCE OF CAPIZ
)
CITY OF QUEZON
) SS.
x----------------------------------------x
ACKNOWLEDGMENT
BEFORE ME, a Notary Public for and in the City of _______, personally
appeared the PRINCIPAL known to be the same person who executed the foregoing
instrument which she acknowledged to me as his free and voluntary act and deed.
WITNESS MY HAND AND SEAL this ___________ at_____, Philippines.