REPUBLIC OF THE PHILIPPINES)

PROVINCE OF ______________ )S.S.

MUN./CITY OF )

SPECIAL POWER OF ATTORNEY

KNOW ALL MEN BY THESE PRESENTS:

That I, ________________________ of legal age, Filipino citizen and resident of

____________________, ____________________, Philippines, by these presents, do hereby NAME,
CONSTITUTE and APPOINT, my wife ___________________________, likewise of legal age,
Filipino citizen and a resident of ______________________, _______________________, to do and
perform for me and in my behalf, places and stead, the following acts and things, namely:

To represent me, make all the necessary transactions and thereafter to make, sign and
execute any documents relative TO WITHDRAWAL and TO DEPOSIT on my account at
___________________________ with account number _______________________, situated
at ________________________, __________________________;

HEREBY GIVING AND GRANTING, my wife being my attorney-in-fact full powers and
authority whatsoever requisite or necessary to be done in and about the premises as to fully as to all
intents and purposes as we might or could lawfully do if personally present and hereby confirming and
ratifying all that my said Attorney-in-Fact shall lawfully do or cause to be done by virtue of these
presents.

IN WITNESS WHEREOF, We have hereunto affixed our signatures this ________ day of
___________________, 20___ at ________________________, _______________________.

_________________________
Atty. In fact

________________________
Principal

SIGNED IN THE PRESENCE OF:

_________________________________ _________________________________

ACKNOWLEDGEMENT

BEFORE ME, this ___________ day of ____________, 20___ at ______________________,

_______________________, a Notary Public for and in the Province of Pangasinan appeared the
above-named parties, known to be the same persons who executed the foregoing Special Power of
Attorney and acknowledged to me that the same is their free act and voluntary deed.

WITNESS MY HAND AND SEAL, the date, month, year and place written above.

Doc. No.________;
Page No.________;
Book No. _______;
Series of 20 _____.