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 but mediation failed;
2. The Pangkat ng Tagapagkasundo was constituted but the personal
confrontation before the Pangkat likewise did not result into a settlement; and
3. Therefore, the corresponding complaint for the dispute may now be filed in
court/government office.
This _________ day of _________, 19_____.
_________________
Pangkat Secretary
Attested by:
____________________
Pangkat Chairman