Republic of the Philippines

City of Manila
Barangay ______

OFFICE OF THE BARANGAY CAPTAIN

_________________________,
Complainant,

- versus - Barangay Case No. _______________

For: ___________________________

__________________________,
Respondent.

x ------------------------------------------------------------------------------------ x

CERTIFICATE TO FILE ACTION

This is to certify that:

Complainant ________________________ (name) and respondent ________________________

(name) failed to or refuse to:

_______ Obey summons or to appear for hearing

_______ No settlement/conciliation was reached

_______ Settlement has been repudiated

And therefore, the corresponding complaint between the parties may now be filed in
court/government office concern.

This ___ day of ___________, 200__.

________________________________
Lupon/Pangkat Secretary

ATTESTED BY:

___________________________
Lupon/Pangkat Chaiman