HLURB Case Form No.

04

SPECIAL POWER OF ATTORNEY

KNOW ALL MEN BY THESE PRESENTS:

I, ______________________________, of legal age, (Nationality)______________, with residence at

_______________________________________________________________________, do hereby
appoint, name and constitute __________________________, likewise of legal age, single/married,
with residence at ___________________________________, as my true and legal representative to
do and perform the following acts and deeds:

1. To file and institute the complaint/answer for and in my name, place and stead, and to execute such
other papers to give full effect to the said complaint /answer, including the verification and
certification against form shopping;

2. To act for and in my name, place and stead and to represent me during the Mandatory Conference
with full authority to enter into amicable settlement under such terms and conditions as may be
acceptable to him/her, to submit to alternative modes of dispute resolution and to make admissions
or stipulations of facts and documents without further consultation from me.

3. To file an appeal or any other petition to protect my interests and likewise with full power and
authority to do and execute such deeds, documents and things as may be proper and necessary to
advance the said interest.

4. I hereby grant my representative full power and authority to execute and perform every act
necessary to render effective the powers herein provided as though I myself have so performed it
and hereby approving all that he may do by virtue of these presents.

In witness whereof, I hereunto set my hand this ___________ day of ______________, 20______, at
______________________________.

_____________________________ _____________________________
Complainant/Respondent Representative

_____________________________ _____________________________
Witness Witness

REPUBLIC OF THE PHILIPPINES )

_____________________________) S.S.

BEFORE ME, a Notary Public for and in _________________________, Philippines, personally

appeared ______________________________, with _______________________________ issued at
____________________ on _____________, known to me and to me known to be the same person
who executed the foregoing special power of attorney and he/she acknowledged to me that the same is
his/her voluntary act and deed.

IN WITNESS WHEREOF, I have affixed my signature and seal on the date and place first
above-written.

Doc. No. ______;

Page No. ______; Notary Public
Book No. ______;
Series of ______.