Republic of the Philippines)

City of Bacolod ) S.S.

x-----------------------------------x

SPECIAL POWER OF ATTORNEY

I, __________________, of legal age, married and resident of

__________________, do hereby name, constitute, and appoint
__________________, of legal age, married and a resident of
__________________, to act in my name, place and stead, to do and perform all or
any of the following:

1. To represent me in all my claims against __________________the local

manning agency that contracted my deceased son, __________________,
onboard foreign fishing vessel __________________, as well as against the
principal company, __________________.

2. To represent me with the with the Philippine Overseas and Employment Agency
(POEA) and secure necessary documents, including but not limited to the Contract of
Employment signed with __________________, Death Certificate, Insurance
Policy from the insuring agency __________________, and any other
documents relevant to my deceased son's employment, and also to secure these
documents from the __________________.

3. To act as my representative with __________________and undertake all

necessary actions to facilitate the settlement of my claims under the insurance policy
related to my deceased son.

4. To promptly initiate any and all relevant legal proceedings on behalf of the principal,
including but not limited to the signing, preparation, and filing of all requisite
pleadings regarding the foregoing before the Department of Labor and Employment
(DOLE), Department of Migrant Workers (DMW), Overseas Workers Welfare
Administration (OWWA), or any appropriate court, tribunal, or quasi-judicial
agency.

5. To represent me in all hearings, preliminary investigations, mediation conferences,

conciliation conferences, judicial dispute resolution, preliminary conference, pre-
trial, trial and other proceedings of said case/s or connected therewith, on such
date/s as may be agreed upon by the parties or as directed by the proper court,
tribunal or quasi-judicial agency;

6. To enter into an amicable settlement that may be arrived at, represent my best
interests, in the simplification of the issues and such other matters as may be taken
up during the pre-trial hearings in the afore-mentioned case/s, to submit this
matter and appear in my behalf at the mediation proceedings of this case before the
Philippine Mediation Center if any;

7. To sign and execute the necessary documents to carry into full effect the power
herein conferred and with special power to make admissions and/or make and
submit as well as to accept and approve compromise proposals upon such terms and
conditions and under such covenants as he may deem fit; and for the purpose to
receive/accept documents and receipts of other documents relative to this purpose;

8. To appoint legal counsel(s) as deemed necessary and appropriate on my behalf for

the aforementioned case/s.

HEREBY GIVING AND GRANTING unto my said Attorney-in-fact full powers and
authority to do and perform all and every act and thing whatsoever requisite or necessary
to carry into effect the foregoing authority, as fully for all intents and purposes as I might or
could lawfully do if personally present; and
 HEREBY RATIFYING AND CONFIRMING all that said Attorney-in-fact shall lawfully do
or cause to be done by virtue hereof.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of August, 2023 in
the _________________________.

Principal

Appointment Accepted:

Attorney-in-fact

SIGNED IN THE PRESENCE OF:

_________________________________ _________________________________

ACKNOWLEDGEMENT

REPUBLIC OF THE PHILIPPINES}

_______________________________________} S.c.
x-------------------------------------------- x

BEFORE ME on this _________day of __________________, in the _______________________________

personally appeared: __________________ with her Government Issued ID with
number _______________ issued at __________________ on ____________________ who is known to me
the same person who executed the foregoing instrument and she acknowledges to me that
the same is of her free and voluntary act and deed.

IN WITNESS WHEREOF, I have hereunto set my hand and seal at the place and date
first above written.

Doc. No. ____

Page No. ____
Book No.____
Series of 2023.