SPECIAL POWER OF ATTORNEY

KNOW ALL MEN BY THESE PRESENTS:

I/WE, _______________________________________________, of legal age, Filipino, with

residence and postal address at
________________________________________________________ do hereby APPOINT
_______________________________________, likewise of legal age, Filipino, with address at
_________________________________________________________ as my/our true
and legal representative to act for and in my/our name and stead and to perform the following acts:

1. To sign/execute all documents relative to the PANTAWID PASADA PROGRAM

including the Deed of Undertaking for Individual PUJ Operators;

2. To faithfully perform all acts/conditions embodied in the Deed of Undertaking

for the Pantawid Pasada Program such that failure of my Attorney-in-fact to
fulfill the conditions of the Deed of Undertaking shall cause the
suspension/cancellation of said card and automatic
suspension/cancellation/disqualification of my account under the Program;

3. To receive the PANTAWID PASADA Card issued under my/our name;

HEREBY GRANTING unto our representative full power and authority to execute and
perform every act necessary to render effective the above acts, as though I/we have so
performed it, and HEREBY APPROVING ALL that he/she may do by virtue hereof with full
right of substitution of his/her person and revocation of this instrument.

IN WITNESS WHEREOF, I/WE HAVE HEREUNTO SET OUR HANDS THIS _____ DAY
OF _______________ 20__, AT ________________________________________.

_______________________________ __________________________________
(Name of Principal) (Name of Agent /Attorney-In-Fact)

Signed in the presence of:

_____________________________ ___________________________________

Republic of the Philippines )

______________________) S.S

BEFORE ME, personally appeared:

Name ID/Proof of Identification Date/Place Issued

_______________________ _______________________ _______________________

_______________________ _______________________ _______________________

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

WITNESS MY HAND AND SEAL, on the date and place first above written.

NOTARY PUBLIC

Doc. No.______;
Page No. ______;
Book No.______;
Series of 20___.