SPECIAL POWER OF ATTORNEY

KNOW ALL MEN BY THESE PRESENTS:

I, _______________, of legal age, married, resident of _____________________________

do hereby name, constitute and appoint my ______________, also of legal age, married, resident of
_________________________ as my true and legal representative to act for and in my name and
stead, to do and perform the following acts, deeds and things, to wit:

1.) To process my application for service connection at ILECO-1

2.) To do such any other act or thing that may be required necessary or incidental to carry
out effectively any and all of the purposes for which this authority is hereby given

HEREBY GIVING AND GRANTING unto my said representative full power and
authority to do and perform all and every act requisite or necessary and proper to be done in the
exercise of any rights and power herein granted, as fully to all intents and purposes as we might or
could lawfully do, if personally present and acting in person, and HEREBY RATIFYING AND
CONFIRMING all that my said representative may also do or cause to be done under and by virtue of
these presents.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 11th day of October 2017
at Iloilo City, Philippines.

_______________________

Principal

Conforme:

______________________

SIGNED IN THE PRESENCE OF:

______________________ ______________________

ACKNOWLEDGMENT

Republic of the Philippines)

City of Iloilo ) S.S.

BEFORE ME, a Notary Public for and in the above jurisdiction personally appeared this
____________________________ day of _____________ 2017

NAME ID/LICENSE No DATE/PLACE OF ISSUE

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

WITNESS MY HAND AND NOTARIAL SEAL.

Doc. No. ____

Page No. ____
Book No. ____
Series of 2017.