Republic of the Philippines

Province of Albay
City of ______________
Barangay _______________________
-o0o-

OFFICE OF THE LUPONG TAGAPAMAYAPA

======================================================================

____________________________ Barangay Case No.

___ _____________________ For:
____________________________ __________________________________
___ __________________________________
Complainant/s

-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 _____________, 20___.

________________________
Lupon Secretary

Attested:

________________________
Lupon Chairman