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Republic of the Philippines

Province of _________
Municipality of _________
BARANGAY ________________

Office of the Punong Barangay

Certificate of Indigency

To Whom It May Concern:

This is to certify that M___________________________________________________,


_____ years old, __________________, Filipino citizen with residence and postal address at
Barangay _______________, Municipality of _________, Province of __________ is one
among the indigent members of this community.

This certification is being issued upon the request of M__________________________


for all legal intents and purposes.

Issued this ______ day of _____________________ at Barangay _______________,


Municipality of _________, Province of __________

_____________________
Punong Barangay

Not valid without seal

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