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I, (____Mother’s name____), of legal age, Filipino, a resident of (___Address___),

do hereby appoint, name and constitute my daughter FLEURDELIZ SAMSON, whose
specimen signature appears herein below as my true and lawful representative to act and in
my name and stead and to perform the following acts, namely:

1. To claim and receive my Certification of Election of Philippine Citizenship issued

by (___Issuing Office____) with office address at (___Address___) under my name ;

2. To sign any documents and other equally important documents pertaining to the
release of my Certification of Election of Philippine Citizenship in my behalf;

GIVING AND GRANTING unto my said attorney-in-fact full power and authority
to do and perform every act and thing whatsoever requisite and necessary to be done in and
about the premises, as fully to all intents and purposes as I might or could do if personally
present, hereby ratifying and confirming all that my said attorney shall lawfully do or cause
to be done by virtue of these presents with full right of substitution of his person and
revocation of the instrument.

IN WITNESS WHEREOF the parties signed this Special Power of Attorney this
___th day of September 2015 at Quezon City, Metro Manila.

FLEURDELIZ SAMSON (___Mother’s Name___)

Attorney-in-Fact Principal


_____________________________ _____________________________



BEFORE ME, a Notary Public, for and in ___________ personally appeared

(______Mother’s Name____) with corresponding identification above-indicated, known to
me to be the same person who executed the foregoing document and acknowledged to me
that the same is his free and voluntary act and deed.

WITNESS MY HAND AND SEAL this ___th day of March 2016.

Notary Public

Doc. No. _____

Page No. _____
Book No. _____
Series of 2016.