AUTHORIZATION

This is to authorize in my behalf,____________________________,____________

First Name,Middle Name,Surname Relationship

____________of ______________________________________to claim/receive

Age Address

my pension due to___________________________________________.

State the reasons for the absences

___________________________________ ____________________________

Signature/Thumbmark Over Signature Over Printed Name of

Printed Name of Beneficiaries Authorized Representative

Attested by:

_____________________________________

MSWDO/CSWDO

_____________________________________

OSCA
 CERTIFICATION

This is to certify that,_________________________________________,

First Name Middle Name Last name

_____of __________________________________can no longer sign in the Social

Age Address

Pension payroll covering the months of____________________CY__________in

the amount of Php______________due
to________________________________.
( State the reason )

Issued this_______day of________________at Tinapian,Manito Albay for

reference purposes.

Attested by;

_______________________
BASCA-President

_______________________
MSWDO/CSWDO

________________________
OSCA-President