Please use BLUE ballpen

Date: _____________________

To: Department of Social Welfare and Development

Field Office XI, Davao City

Letter of Authority To Receive

I,__________________________________________, ______ years old and resident of
(Name of Senior Citizens) (Age)

___________________________________________________________________ authorizes
(Street, Barangay, Municipality/City)

Mr./Ms. ____________________________________ who is my _________________________

(Name of Authorized Representative) (Relationship To the Beneficiary)

whose specimen signature / thumbmark appears below to receive on my behalf my monthly

stipend as Indigent Senior Citizen for the period JANUARY – JUNE 2023 in the total amount of
(months covered)
Three thousand pesos only. (Php 3, 000).
(Amount in words)

I cannot claim my stipend because of the following reason:

Sick/Bedridden

PWD

Old Age

Others: _______________________
Respectfully yours,

_______________________________
Signature/ thumbmark of Beneficiary

OSCA ID No. ____________________

(Attach 1 photocopy with 3 specimen signatures)

___________________________________________
(Name and Signature of Authorized Representative)

Address: ___________________________________
ID No.: _____________________________
(Attach 1 photocopy with 3 specimen signatures)

Witnessed by: Noted by:

____________________________ ____________________________________
Name and Signature of Brgy. Captain or Chapter Name and Signature of OSCA Head/MSWDO
President