SPECIAL POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS:
I, _____________________, Filipino Citizen, of legal age, single/married, and with residence at
____________________________ do hereby name, appoint, and constitute the Department of HealthNational Capital Regional Office (DOH-NCRO) through its designated/authorized personnel holding
plantilla position to be my true and lawful attorney-in-fact and legal representative, for me and in my name,
place and stead to act in, manage, and conduct all my affairs and any or all of the necessary acts and things
relative to the Substituted Filing with Revenue District Office (RDO) 41-Mandaluyong of my Income Tax
Return for appropriate withholding taxes on income payments being made to me under my Contract of
Service as _____________________.
The authority herein stated shall remain valid and effective unless I expressly revoke the same through a
written notice to the DOH-NCRO.
HEREBY GRANTING AND GIVING unto my said Attorney-in-fact full powers and authority to do and
perform all and every act requisite or necessary to render effective the foregoing authority to transact with
the RDO 41-Mandaluyong as though I myself have so performed it, and HEREBY APPROVING ALL that
the said Attorney-in-Fact shall lawfully do or cause to be done by virtue hereof.
IN WITNESS WHEREOF, I have hereunto set my hand this ____________ day of ___________, 2017 in
_______________, ______________________
_________________________________
Principal
Government-Issued Valid ID:_______________
ID No. _________________________________
Date of Issue: ___________________________
Expiry Date:____________________________
Conforme:
DOH-NCRO through designated/authorized personnel:
__________________________
Attorney-in-Fact
ID _________No. ________
Date of Issue _________
Expiry Date __________
Signed in the presence of:
____________________
Witness
______________________
Witness
ACKNOWLEDGEMENT
Republic of the Philippines )
_________ ________________ ) s.s.
BEFORE ME, a Notary Public for and in ____________, appeared _________________________ with
his/her _______________________ (government-issued valid ID) known to me and to me known to be the same
person who executed the foregoing instrument and who acknowledged to that the same is his free and voluntary act
and deed.
WITNESS MY HAND AND SEAL on _____________________________ at ______________________.
NOTARY PUBLIC
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