Authorization

This is to authorize in my behalf, ___________________________________________________

First name , Middle name, Last name

_______________________________ of _______________________________ to claim/receive

Relationship to beneficiary and age Address

my social pension amounting to Php. 3,000.00 for the period of

___________________________ due to _________________________________________
Months covered State the reason for the absence

__________________________________ ___________________________________
Signature / Thumbmark Signature / Thumbmark
Over Printed Name of the Social Pensioner Over Printed Name of the Authorized
Representative

Attested by:

EDEN YL. LEE___

MSWDO / CSWDO

__FLORA A. ORAYAN_
OSCA