Republika ng Pilipinas

LALAWIGAN NG RIZAL

Road A Phase IV COGEO Village, Barangay Bagong Nayon, Antipolo City 1870 Rizal, Philippines
 barangay_bagongnayon@yahoo.com   647-0942   942-0358   bagongnayon.antipolo@gmail.com
www.facebook.com/BagongNayonOfficialPage   www.antipolo.ph

KP PORMULARYO BLG. 21

BARANGAY CASE NO. _______________

____________________________
COMPLAINANT/S
____________________________
____________________________
(Address)

AGAINST: FOR:

____________________________ ____________________________________
RESPONDENT/S
____________________________ ____________________________________
Barangay Bagong Nayon,Antipolo City
(Address)

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 __________, 20____.

____________________
Pangkat Secretary

Attested:

____________________
Pangkat Chairman

Barangay Bagong Nayon: Kabalikat sa Kaunlaran at Pagbabago ng Lungsod ng Antipolo.