SPECIAL POWER OF ATTORNEY

KNOW ALL MEN BY THESE PRESENTS: I, _____________________, of legal age, with residence at _____________________, do hereby NAME, APPOINT and CONSTITUTE, _____________________, of legal age, ili!ino, with office at _____________________, to be "y tr#e and lawf#l attorneys to act in, "anage and cond#ct all "y affairs, and for that !#r!ose in "y na"e and in "y behalf to do and e$ec#te all of any of the following acts, deeds and things, to wit% &' To recei(e and collect fro" the Social Sec#rity Syste" any and all s#"s of "oney)chec*s which I "ay clai" as f#neral benefits arising fro" the death of "y h#sband, _____________________+ ,' To re!resent, e$ec#te, !ay the fees re-#ired, sign any and all doc#"ent.s/ and !a!er.s/ as well as clai")recei(e for and in "y behalf said doc#"ent.s/ fro" the Social Sec#rity Syste" as well as to do any and all acts in order to acco"!lish the aforestated acts and deeds' My attorney0in fact hereby acce!ts this a!!oint"ent s#b1ect to its ter"s and agrees to act and !erfor" in said fid#ciary ca!acity consistent with "y best interest as they in their best discretion dee"s ad(isable, and I affir" and ratify all acts so #nderta*en' 2I3IN2 AN4 25ANTIN2 #nto said attorney0in0fact f#ll !ower and a#thority to do and !erfor" all and e(ery act and thing whatsoe(er re-#isite and necessary to be done in and abo#t the !re"ises, hereby ratifying and confir"ing all that said attorney0in0fact shall lawf#lly do or ca#se to be done by (irt#e of these !resents' IN 6ITNESS 67E5EO , I ha(e here#nto affi$ed "y signat#re this ___day of A#g#st, ,8&9 at __________________________'

______________________________ Princi!al 6ith "y confor"ity% _____________________ Attorney0in0fact

Signed in the !resence of% ______________________________ _________________________

ACKNOWLEDGMENT 5EPU:;IC O T7E P7I;IPPINES/ ________________________ /S'S' :E O5E ME, a Notary P#blic for and in the _____________ of _______________, this ____ day of A#g#st , ,8&9, !ersonally a!!eared%

NAME

GOVERNMENT ISSUED ID

DATE AND PLACE ISSUED

All *nown to "e and to "e *nown to be the sa"e !erson who e$ec#ted the foregoing S!ecial Power of Attorney and he ac*nowledged to "e that the sa"e is his free and (ol#ntary act and deed' This S!ecial Power of Attorney consists of two .,/ !ages, incl#ding this !age whereon this ac*nowledg"ent is written' IN WITNESS WHEREOF, I ha(e here#nto set "y hand and affi$ed "y notarial seal on the !lace and date first abo(e0written'

NOTA5< PU:;IC

4oc' No' ____+ Page No' ____+ :oo* No' ____+ Series of ,8&9'