You are on page 1of 1

Date

AUTHORIZATION LETTER

I, , recipient of Social Pension stipend, of legal age,


(Name of Social Pensioner)

Presently under the custody of my child/relative, _____, in


(Name of custodian)

, with contact number of


(Complete address)

Authorizes my ,
(Relationship to beneficiary) (Name of Authorized rep)

Who is presently residing in , to claim my


(Complete address of authorized Rep)

Stipend in the amount of:

-1st Quarter CY
-2nd Quarter CY
-3rd Quarter CY
-4th Quarter CY

Due to reason stated below:

-Bedridden
-Sick
-With physical disability
-Lockdown in other areas
Please specify the area

That I am fully that he/she will affix his/her signature in the payroll for and in my behalf.
Thank you.

(Signature over printed name of beneficiary)

Conformed by:

Signature over printed name of Authorized Representative

Attested by:

Signature over printed name of SC Brgy. Chapter President

You might also like