Republic of the Philippines

PROVINCE OF NORTHERN SAMAR

Municipality of Mondragon

Barangay San Jose

OFFICE OF THE PUNONG BARANGAY

BARANGAY CLEARANCE

TO WHOM IT MAY CONCERN:

This is to certify that. , a legal age, and Filipino citizen ( ) married, ( )single and ( )
widow withis bonafide resident of Barangay San Jose, Mondragon, Northern Samar who is personally
known to me to be of good moral character and law abiding citizen in the community. He / she has no
criminal record found in our office or Barangay Records.

This certification is being issued upon the request of the aforementioned to support his /
her applying to requirement purpose only.

Issued upon the request to the interested party this. day of 20 at Barangay San Jose,
Mondragon, Northern Samar.

Certified By:

Hon. ALEJANDRO L. AGUILANDO

Punong Barangay

O.R. No._________

Community Tax Certificate No.: _______

Issued on: _________

Issued at: Barangay San Jose Mondragon, Northern Samar.