Republic of the Philippines

Province of _________
Municipality of _________
BARANGAY ________________

Office of the Punong Barangay

CERTIFICATION

To Whom It May Concern:

This is to certify that Mr. _____________________________________, _____ years old

and Miss _____________________________________, _____ years old, both Filipino citizens

with residence and postal address at Barangay _______________, Municipality of _________,

Province of __________, are live-in couple.

This certification is issued for all legal intents and purposes.

Issued this _______ day of ___________________________ at Barangay ___________,

Municipality of _________, Province of __________

_____________________
Punong Barangay

Not valid without seal