BOHONG-BOHONGAN

18 December 2008 mulyono
Off
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Claims Department Office,
Boeing Avenue 9459 PE.
Amsterdam-The Nederland
TEL: 0031-651-781-312.
FAX: 0031-847-323-655.
POWER OF ATTORNEY

A POWER OF ATTORNEY IS A DOCUMENT, WHICH GIVES SOMEONE THE AUTHORITY TO ACT ON YOUR BEHALF ON MATTERS THAT YOU SPECIFY.
I, Mr./Mrs./Madam: ______MULYONO______________________________________

Born on: KLATEN_ At:___ AUGUST’28, 1971_______________________

Residing at (Address): BENDUNGAN RT 03/06, KLODRAN, COLOMADU, KARANGANYAR

State: __JAWA TENGAH_________________ Country: _INDONESIA_______________

With my Proof of Identification attached Number: ___________________

BECAUSE OF MY INABILITY TO ATTEND THE SIGNING CEREMONY OF THE RELEASE ORDER OF THE WINNING PRIZE OF MY E-MAIL,

do hereby Empower Barr. Blenheim Mark – Head, Legal Department-

STAATS NEDERLAND, Nederlandse Staatsloterij Postbus 3334 5902 RH Venlo, Nederlandse to;

1. Sign for and retrieve the Notaris of the Transfer of my Winning Prize €1,000,000.00 (One Million Euro) only in the International Staatsloterij Email Sweepstakes, Nederland from the International Court of Justice, Justitielaan 60, 2518 KH, The Hague, ON MY BEHALF.

2. Sign the Release Order of my Winning Fund to be paid as I have indicated in the Payment Scheme Form B6 during the Signing/Award Ceremony on the __________________________, ON MY BEHALF.

3. Collect the Award Winning Certificate of my Email during the Award Ceremony, ON MY BEHALF.

Date:….17 DECEMBER 2008. Signature:……………………

PRINT OUT THIS FORM, COMPLETE PROPERLY AND SEND BACK BY FAX OR
AS EMAIL ATTACHMENT AFTER SCANNING:

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