Republic of the Philippines

Barangay _________________
Legazpi City

________________________
Date

AUTHORIZATION

This is to authorize in my behalf, ___________________________________________________,

First Name, Middle Name, Last Name

__________________________________, ______ years old, of ___________________________to

(Relationship to beneficiary) (Address)

claim/ receive my DSWD’s Cash-for-Work for Persons with Disabilities amounting to

Php. 3,450.00 due to ____________________________________________________________.

(State the reason for the absence)

_______________________________ ______________________________________
Signature/Thumb mark over Signature/Thumb mark over
Printed Name of the Beneficiary Printed Name of the Authorized Representative

Attested by:

_______________________________
Punong Barangay