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Annex3_Authorization

This document is an authorization form for a social pension beneficiary to allow an authorized representative to claim their stipend for a specific semester. It requires the beneficiary's personal information, the representative's details, and a reason for the beneficiary's inability to claim the stipend personally. The form must be signed by the beneficiary and witnessed by a local official.

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Jeshella Roxas
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139 views

Annex3_Authorization

This document is an authorization form for a social pension beneficiary to allow an authorized representative to claim their stipend for a specific semester. It requires the beneficiary's personal information, the representative's details, and a reason for the beneficiary's inability to claim the stipend personally. The form must be signed by the beneficiary and witnessed by a local official.

Uploaded by

Jeshella Roxas
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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DSWD-GF-010A | REV 00 | 22 SEP 2023

ANNEX 3

OSCA ID No.
NCSC RRN: (If Applicable)

Date:______________

AUTHORIZATION
(For Authorized Representative)

I am ___________________________________________, born on __________________,


(Name of the Social Pension Beneficiary) (Month, Date, Year)

Social Pension Beneficiary from _______________________________________________.


(Permanent Resident Address)

That I am authorizing my ______________________, ______________________________


(Relationship to the pensioner) (Name of Authorized Representative)

to claim my stipend for the ___________ semester for the year ______________ since I am

_________________________________________________________________________
(state reason/s on the inability to personally claim the social pension stipend)

and signed any legal document/s corresponding to the amount of the Social Pension stipend.

_______________________________________________
(Name and Signature or Thumbmark of Social Pension Beneficiary)

Witnessed by:

_________________________________
Punong Barangay/ Kagawad/ OSCA or LSWDO
(Signature over Printed Name)

PAGE 1 of 1
DSWD Field Office VIII, Government Center, Candahug, Palo, Leyte, Philippines 6501
Email: [email protected] website: https://fo8.dswd.gov.ph Telephone No. (053) 552-3698

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