SPECIAL POWER OF ATTORNEY

KNOW ALL MEN BY THESE PRESENTS:

I, ________________, of legal age, with residence and postal address at

__________________, by these presents hereby constitute, name and appoint
________________, likewise of legal age, with postal address at __________________
as my true and legal representative to act on my behalf and in my name, to
execute and perform all or any of the following acts, deeds, matters and thing, in
connection with the application, procurement and registration of my birth
certificate to wit:

a. To register my Birth Certificate in the Local

Civil Registry of Negros ________.
b. To apply for and secure a certified true copy of
my birth certificate issued by the Local Civil
Registry of Negros _____________;
c. To procure such other documents pertaining
to the application of the same;
d. To perform any and all acts and deeds as well
as to execute, sign, deliver, submit, follow-up,
receiver, enter into and conclude, any and all
documents, papers, and to comply with any
and all requirements, terms and conditions,
necessary, incidental and required for the
immediate processing of the said certified copy
of my birth certificate.

HEREBY GRANTING unto my representative full power and authority

to execute and perform all and every act necessary to render effective then
foregoing powers as fully to all intents and purposes as I might or cold
lawfully do if personally present, with full power of substitution or
revocation, and hereby ratifying and confirming all that my said attorney or
her substitute shall lawfully do or cause to be done by virtue hereof.

IN WITNESS WHEREOF , I HAVE HEREUNTO SET MY HANDS THIS

____ DAY OF _______________ 20__, in the City of Manila.

_________________________ ____________________________________
(Name of Principal) (Name of Agent /Attorney-In-Fact)
 Signed in the presence of:

_____________________________ ___________________________________

Republic of the Philippines )

_________________________ ) S.S

BEFORE ME, a Notary Public for and in ________________, this _____day of

__________________, personally appeared:

Name Competent Evidence Date/Place

of Identity Issued

known to me and to me known to be the same persons who executed the

foregoing instrument and she swore and further acknowledged to me that the
same is her free and voluntary act and deed.

WITNESS MY HAND AND SEAL, on the date and place first above written.

Notary Public

Doc. No.______;
Page No. ______;
Book No.______;
Series of 20___.