Republic of the Philippines

Municipality of ___________________
Province of ________________
BARANGAY ________________
OFFICEOF THE PUNONG BARANGAY

CERTIFICATE OF INDIGENCE
TO WHOM IT MAY CONCERN:
This is to certify that _____________________________________, of legal age,
male/female, single/married/widow/widower, Filipino citizen, with residence at No. ____,
_________________ Street, Barangay ________________, this City/Municipality, whose
specimen signature appears below, is an INDIGENT and has no means of income.
This certification is being issued upon the request of the above-named person for
whatever legal purpose it may serve him/her.
Issued this ____ day of _____________ 20____ at Barangay _______________,
___________, _____________, Philippines.

Specimen Signature:
__________________________
__________________________
Punong Barangay

Amount Paid: _________

O.R. No. _____________
Date: ________________

Not valid without official seal. Not valid without official receipt.