Special Power of Attorney: Doc. No. - Page No. - Book No. - Series of 20

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FORM 5-SCC

SPECIAL POWER OF ATTORNEY


KNOW ALL THESE MEN BY THESE PRESENTS:

I, _______________________, of legal age, single/married, with residence


at _______________________ do hereby appoint, name and constitute
_________________________, likewise of legal age, single/married, with
residence at __________________ as my true and legal representative to act for
and stead and to represent me during the hearing of Civil Case No.
________________, to enter into amicable settlement, to submit to alternative
modes of dispute resolution and to make admissions or stipulations of facts
and documents without further consultation from me.

I hereby grant my representative full power and authority to execute and


perform every act necessary to render effective the power to compromise as
though I myself have so performed it and hereby approving all that he may do
by virtue of these presents.

In witness whereof, I hereunto set my hand this _____________ day of


______________________ , 20____, at ____________________.

__________________________
Principal

_____________________________
Agent

Witnesses:___________________________ __________________________

A C K N O W L E D G M E N T

REPUBLIC OF THE PHILIPPINES)


PROVINCE OF ) S.S.

BEFORE ME, this ____th day of ____________ 20____, at


_________________, Philippines, personally appeared,
_______________________________ with ______________
issued___________________ on____________________, known to me to be the
same person who executed the foregoing instrument and acknowledged to me
that the same is her free act and voluntary deed.

IN WITNESS WHEREOF, I have hereunto set my hand and affixed my


notarial seal the day, year and place above written.

Doc. No. ____;


Page No. ____;
Book No. ____;
Series of 20___.

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