FORM 7-SCC

SPECIAL POWER OF ATTORNEY

KNOW ALL 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 ______________________________, who is related to me and/or is my next-of-kin, and is not a lawyer, as my true and legal representative to act for and in my name 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 _______________ _______________.

Witnesses:

REPUBLIC OF THE PHILIPPINES)

CITY/MUNICIPALITY OF ______) SS.

ACKNOWLEDGMENT

BEFORE ME, a Notary Public for and in the (Province/City/Municipality) of _____________, personally appeared _____________ with Community Tax Certificate No. _____________ issued on _____________ at _____________ (and Tax Identification No. (T.I.N.) _____________), known to me and to me known to be the same person who executed the foregoing instrument which (he/she) acknowledged to me as (his/her) free and voluntary act and deed, consisting of only ______ (____) page/s, including this page in which this Acknowledgement is written, duly signed by (him/her) and (his/her) instrumental witnesses on each and every page hereof.

WITNESS MY HAND AND SEAL this _____________ at _____________, Philippines.

NOTARY PUBLIC

Doc. No. ______;

Page No. ______;

Book No. ______;

Series of ______;