Republic of the Philippines

Province of __________
CITY/MUNICIPALITY OF ______________
Barangay _________________
OFFICE OF THE LUPONG TAGAPAMAYAPA
___________________
___________________
Complainant/s

Barangay Case No. ________________

For: ____________________________
________________________________
________________________________

against
__________________
__________________
Respondent/s
CERTIFICATION TO FILE ACTION
This is to certify that:
1. There has been a personal confrontation between the parties before the
Punong Barangay/Pangkat ng Tagapagkasundo;
2. A settlement was reached;
3. The settlement has been repudiated in a statement sworn to before the
Punong Barangay by ______________ on ground of ______________; and
4. Therefore, the corresponding complaint for the dispute may now be filed in
court/government office.
This _________ day of __________, 19____.
___________________
Lupon Secretary
Attested:
__________________
Lupon Chairman