Ltia Form 01-Performance Evaluation Form

CY LUPONG TAGAPAMAYAPA INCENTIVES AWARDS (LTIA)
LTIA FORM 01-PERFORMANCE EVALUATION FORM
A. IDENTIFYING INFORMATION
Lupong Tagapamayapa ______________________________
City/Municipality ______________________________
Region ______________________________
Category ______________________________
B. EVALUATION CRITERIA
CRITERIA ASSIGNED POINT

SCORE
I. EFFICIENCY IN OPERATIONS 35
A. Observance of Settlement Procedure and Settlement 15
Deadlines
B. Systematic Maintenance of Records 5
C. Timely Submission of Reports to Concerned Agencies 5
D. Conduct of monthly meetings exclusively on KP matters 10
II. EFFECTIVENESS IN SECURING THE SETTLEMENT OF 30

INTERPERSONAL DISPUTE OBJECTIVE OF THE
KATARUNGANG PAMBARANGAY (KP)
A. Quantity of settled cases against filed 10
B. Quality of Settlement of Cases 10
C. At least 80% compliance with the terms of settlement or 10
award after the cases have been settled
III. CREATIVITY AND RESOURCEFULNESS OF THE 25
LUPONG TAGAPAMAYAPA
A. Settlement Technique 5
B. Coordination with concerned agencies relating to 5
disputes filed
C. Sustained information drive to promote KP 5
E. KP Training or seminar within the assessment period 10
IV. AREA OR FACILITY FOR KP ACTIVITIES 5
V. FINANCIAL OR NON-FINANCIAL SUPPORT 5
TOTAL POINT SCORE 100
1|LTIA FORM 01-PERFORMANCE EVALUATION FORM
LTIA FORM 01-PERFORMANCE EVALUATION FORM
C. WE CERTIFY TO THE CORRECTNESS OF THE ABOVE INFORMATION.
_____________________________
Chairperson - ___________Awards Committee
_____________________________
Vice Chairperson - ___________Awards Committee
_____________________________
Member - ____________Awards Committee
______________________________
_____________________________
______________________________
D. DATE ACCOMPLISHED
_____________________________________
2|LTIA FORM 01-PERFORMANCE EVALUATION FORM

LTIA FORM 02-CONSOLIDATED PERFORMANCE EVALUATION FORM
Lupong Tagapamayapa ______________________________
Region ______________________________
Category ______________________________
B. CRITERIA AND PERFORMANCE RATING
CRITERIA ASSIGNED PERFORMANCE TOTAL AVERAGE

POINT RATING POINT POINT
SCORE EVALUATOR SCORE SCORE
1 2 3 4 5
I. EFFICIENCY IN 35
OPERATIONS
A. Observance of 15
Settlement
Procedure and
Settlement
Deadlines
B. Systematic 5
Maintenance of
Records
C. Timely Submission 5
of Reports to
Concerned
Agencies
D. Conduct of 10
monthly meetings
exclusively on KP
matters
II. EFFECTIVENESS IN 30
SECURING THE
SETTLEMENT OF
INTERPERSONAL
DISPUTE OBJECTIVE OF
THE KATARUNGANG
PAMBARANGAY (KP)
A. Quantity of settled 10
cases against filed
3|LTIA FORM 02-CONSOLIDATED PERFORMANCE EVALUATION
FORM
B. Quality of 10
Settlement of Cases
C. At least 80% 10
compliance with
the terms of
settlement or award
after the cases have
been settled
III. CREATIVITY AND 25
RESOURCEFULNESS OF
THE LUPONG
TAGAPAMAYAPA
A. Settlement 5
Technique
B. Coordination with 5
concerned agencies
relating to disputes
filed
C. Sustained 5
information drive to
promote
Katarungang
Pambarangay 10
D. KP Training or
seminar within the
assessment period
IV. AREA OR FACILITY 5

FOR KP ACTIVITIES
V. FINACIAL OR NON- 5
FINANCIAL SUPPORT
GRAND TOTAL POINT

SCORE
100
OVERALL
PERFORMANCE RATING
FORM
_____________________________
_____________________________
_____________________________
______________________________
_____________________________
______________________________
_____________________________________

FORM
LTIA FORM 03 [C/M]-COMPARATIVE PERFORMANCE EVALUATION FORM
Province ______________________________
Region ______________________________
Category ______________________________
B. COMPARATIVE EVALUATION RESULTS
LUPONG TAGAPAMAYAPA (LT) OVERALL ADJECTIVAL RANK

PERFORMANCE RATING
RATING
1.
2.
3.
4.
5.
n
_____________________________
_____________________________
_____________________________
______________________________
_____________________________
______________________________
_____________________________________
6|LTIA FORM 03 [C/M]-COMPARATIVE PERFORMANCE

EVALUATION FORM
LTIA FORM 03 [P]-COMPARATIVE PERFORMANCE EVALUATION FORM
Province ______________________________
Region ______________________________
Category ______________________________
LUPONG TAGAPAMAYAPA (LT) OVERALL ADJECTIVAL RANK

PERFORMANCE RATING
RATING
1.
2.
3.
4.
5.
n
_____________________________
_____________________________
_____________________________
______________________________
_____________________________
______________________________
_____________________________________
7|LTIA FORM 03 [P]-COMPARATIVE PERFORMANCE EVALUATION

FORM
LTIA FORM 03 [R]-COMPARATIVE PERFORMANCE EVALUATION FORM
Region ______________________________
Category ______________________________
LUPONG TAGAPAMAYAPA OVERALL ADJECTIVAL RANK

(LT) PERFORMANCE RATING
RATING
1.
2.
3.
4.
5.
n
_____________________________
_____________________________
_____________________________
______________________________
_____________________________
______________________________
_____________________________________
8|LTIA FORM 03 [R]-COMPARATIVE PERFORMANCE EVALUATION

FORM
LTIA FORM 04-PERFORMANCE VALIDATION REPORT FORM
1. VALIDEE LT___________________ 1. VALIDEE LT______________________
2. FINDINGS_____________________ 2. FINDINGS________________________
______________________________ _________________________________
3. RECOMMENDATION(S)
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
4. WE CERTIFY TO THE CORRECTNESS OF THE ABOVE INFORMATION.
_____________________________
_____________________________
_____________________________
______________________________
_____________________________
______________________________
DATE ACCOMPLISHED
_____________________________________
9|LTIA FORM 04-PERFORMANCE VALIDATION REPORT FORM

LTIA FORM 05-OFFICIAL ENTRY FORM
Date __________________
_______________________
_______________________
The Chairperson
National Awards Committee
Sir/Ma’am:
We are pleased to transmit the list of Regional Finalists for CY Lupong Tagapamayapa
Incentives Awards (LTIA) together with their respective documentation reports, as
follows:
Highly Urbanized Cities Category ____________________________________

Component Cities Category ____________________________________
1st-3rd Class Municipalities Category ____________________________________
4th-6th Class Municipalities Category ____________________________________
Please find the following enclosures:

(1) Original copy of LTIA Form 03 [R]-Comparative Performance Evaluation Form
duly accomplished and signed by the Regional Awards Committee;
(2) Certified true copies of LTIA Forms 03 [P] and 03 [C/M]-Comparative
Performance Evaluation Forms duly accomplished and signed by the
Provincial/City/Municipal Awards Committee;
(3) Original copy of LTIA Form 06-Summary of Cases duly accomplished and signed
by the Lupon Secretary, Lupon Chairman, C/MLGOO and LTIA Regional Focal
Person;
(4) Original copy of LTIA Form 07-Performance Highlights with required
attachments duly accomplished and signed by the Lupon Secretary, Lupon
Chairman, C/MLGOO and LTIA Regional Focal Person; and
(5) Original copy of LTIA Form 07-A-List of Cases duly accomplished and signed by
the Lupon Secretary and Lupon Chairman.
Very truly yours,
_____________________________
Chairperson, Regional Awards Committee (RAC)
10 | L T I A F O R M 0 5 - O F F I C I A L E N T R Y F O R M
LTIA FORM 05-OFFICIAL ENTRY FORM
______________________________ ______________________________
Vice Chairperson, RAC Member, RAC
______________________________ _____________________________
Member, RAC Member, RAC
______________________________ _____________________________
11 | L T I A F O R M 0 5 - O F F I C I A L E N T R Y F O R M
LTIA FORM 05-A : NON-SUBMISSION OF OFFICIAL ENTRY
_______________________
_______________________
The Chairperson
National Awards Committee
Sir/Ma’am:
We would like to inform you that based on the assessment of the different Awards
Committees, Barangay Lupons under the Category did not qualify in the selection of
LTIA nominees for the national level. Listed below are the following reason/s for the
non-submission of nominees:
REASON/S:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Please find the following enclosures:

(1) Original copy of LTIA Form 03 [R]-Comparative Performance Evaluation
Form duly accomplished and signed by the Regional Awards Committee;
(2) Certified true copies of LTIA Forms 03 [P] and 03 [C/M]-Comparative
Performance Evaluation Forms duly accomplished and signed by the
Provincial/City/Municipal Awards Committee;
Very truly yours,
_____________________________
Chairperson, Regional Awards Committee (RAC)
________________________ _________________________
Vice Chairperson, RAC Member, RAC
________________________ _________________________
________________________ _________________________
12 | L T I A F O R M 0 5 - A : N O N - S U B M I S S I O N O F 0 F F I C I A L E N T R Y
LTIA FORM 06-SUMMARY OF CASES
CATEGORY:
____________________________
FINALIST LUPONG TAGAPAMAYAPA : POPULATION :
PUNONG BARANGAY: LAND AREA :
CITY/MUNICIPALITY : TOTAL NO. OF CASES:
MAYOR: NUMBER OF LUPONS:
PROVINCE: MALE :
REGION: FEMALE :
General Instruction: Please read the Technical Notes at the back before accomplishing this form. Supply only the number.
NATURE OF CASES ACTION TAKEN

(1) OUTSIDE THE BUDGET
TOTAL
JURISDICTION ALLO-
SETTLED NOT SETTLED (cases
OF THE CATED
(2) (3) filed)
BARANGAY (6)
(5)
CERTIFIE DROP-
CRIMI CIVI MEDIA- CONCI- ARBIT- PEN- DIS- REPU- D TO FILE PED/
OTHERS TOTAL TOTAL TOTAL
-NAL L TION LIATION RATION DING MISSED DIATED ACTION IN WITH--
(1c) (1D) (2D) (3F)
(1a) (1b) (2a) (2b) (2c) (3a) (3b) (3c) COURT DRAWN
(3d) (3e)

***Total Number of Lupons excluding Lupon Chairman and Lupon Secretary

13 | L T I A F O R M 0 6 - S U M M A R Y O F C A S E S S
***Please attached Form 06-A “LIST OF CASES”

Guidance on counting: (NOT INCLUDED IN THE SUBMISSION)
Settled Cases are those cases that undergone KP process such as Mediation, Conciliation and Arbitration without repudiation and
recurrence of cases settled by the Lupon.
Unsettled Cases are defined as follows:

 Dismissed Cases –cases where complainant and/or respondent after due notice, refuses or willfully fails to appear without
justifiable reason on the date set for mediation, conciliation or arbitration. Such dismissal ordered by the Punong
Barangay/Pangkat Chairman after giving the complainant and/or respondent an opportunity to explain his non-appearance
shall be certified by the Lupon or Pangkat Secretary as the case may be, and shall bar the complainant and/or respondent from
seeking judicial recourse for the same cause of action as that dismissed.
 Pending - those cases which have been filed within assessment period but was not able to settle within the assessment period.
 Dropped/Withdrawn - cases where either party shows no intention to continue the process of settling their dispute and
decided to withdraw or dropped the case in the Barangay level. This should be proven by a written document signed by both
parties stating their lack of intention to continue the case.
 Repudiated is where one of the parties refused to perform the settlement or the arbitration award and file a repudiation to the
Punong Barangay within the prescribed period set under the Revised Katarungang Pambarangay Law. Within 10 days from
the date of settlement in case of settlement agreement while within five (5) days from the date of the arbitration award.
Outside the Jurisdiction of the Barangay. These are cases which may be brought to the Barangay level but shall only be recorded in
the Barangay and later on endorsed to the proper office which can give it the appropriate action. This is not included in the total
number of cases filed.
LTIA FORM 07-PERFORMANCE HIGHLIGHTS
Category
Name of the Lupong Tagapamayapa
Punong Barangay
City/Municipality
Mayor
Barangay Logo Here
Province
Region
IRA
Land Area
Population
LTIA Awards Received (all levels)
GENERAL INSTRUCTION: Kindly fill-out this form by following the instructions stated per sub-criteria.
CRITERIA
I. EFFICIENCY IN OPERATIONS
A). Observance of  Describe how the Lupon Secretary records every dispute and attach two (2) photos of the record book and sample
Settlement entries in the record book with caption.
Procedure and
Settlement NOTE: Record Book entries should contain docket number, names of the parties, date and time filed, nature of the case and
Deadlines
disposition.
1) a) Proper
Recording
of every
dispute
16 | L T I A F O R M 0 7 - P E R F O R M A N C E H I G H L I G H T S
2)  Briefly describe the actual
Settlement and experience of the Lupong Tagapamayapa in handling the cases filed in the Barangay.
Award Period (Note: Please do not state the provision of the KP Law re: settlement and award period.)
 Kindly fill-out the table below. First line is filled-out as guide.
 Provide how many case/s is settled through Mediation, Conciliation, Conciliation with Extendible Period, Arbitration
and Conciliation beyond 46 days.
 Attach four (4) photos with caption of on-going settlement of dispute.
SETTLEMENT AND AWARD PERIOD

C46+ -Conciliation beyond 46
LEGEND: M-Mediation C-Conciliation A-Arbitration C w/ EP-Conciliation with Extendible Period
days
CASE CASE TITLE COMPLAINT NATURE DATE DATE OF INITIAL ACTION TAKEN DATE OF
NO. TITLE FILED CONFRONTATION (M, C, C w/ EP, SETTLEM
OF PARTIES A and C46+) ENT
2016-01 Juan Dela Cruz vs. Collection of January January 25, 2016 M January 28,
Juana Change Sum of Money Civil 22, 2016 2016
B. Systematic  Describe the techniques the Lupon Secretary used in keeping a systematic maintenance of records.
Maintenance of  Provide two (2) Photos with caption of each:
Records a) Record Books in
reference to the
assessment year
b) Computerized records of cases
c) Compilation of the Notices of Meetings, Minutes of Lupon Meetings with Attendance Sheets
d) Compilation of Copies of Reports submitted to the Court and to the DILG
e) Filing cabinet/s
 Kindly fill-out the table below and attach transmittal letters of reports submitted to the concerned agencies. First line
C. Timely Submission
is filled-out to serve as guide.
of Reports to
Concerned Agencies TIMELY SUBMISSION OF REPORTS
DATE OF SUBMISSION REPORT/S SUBMITTED AGENCY
April 4, 2016 KP Quarterly Consolidated Reports DILG
Monthly Transmittal of Final Reports MTC
A. Conduct of  Please provide the information needed in the table below and attach the following: (Please see sample in the first line)
Monthly Meetings a) Copy of Notices of Meetings
Exclusively b) Minutes of Lupon
on Katarungang Meetings
Pambarangay (KP) c) Three (3) photos with caption of on-going meeting.
Matters
SUMMARY OF LUPON MEETINGS
DATE OF NOTICE OF DATE OF THE MEETING AGENDA
MEETING MEETING
February 1, 2016 February 6, 2016  Number of cases on January 2016.
 On-going cases.
II. EFFECTIVENESS IN SECURING THE SETTLEMENT OF

INTERPERSONAL DISPUTE OBJECTIVE OF THE KATARUNGANG PAMBARANGAY
A. Quantity of Please provide
Settled cases brief explanation and the computation
against filed based on the definition provided.
Formula: Total Number of Settled Cases X 100

Total number of cases filed
Please attach Form 7-A, List of Cases
B. Quality of
Settlement of Cases Please supply the necessary information and briefly explain how the Lupong Tagapamayapa achieved such quality of
settlement of cases.
Out of the (Total number of Settled Cases), there is only (Percentage of repudiated case/s).
i.e. Out of the 200 settled cases, there is only 2% of repudiated cases.
Out of the (total number of settled cases), there is only (Percentage of non-recurrence) of cases settled by the Lupon.
i.e. Out of the 200 settled cases there is no recurrence of cases settled by the Lupon.
C. At least 80%  Please supply the necessary information and briefly explain how the Lupong Tagapamayapa achieved such quality of
compliance with settlement of cases.
the terms of
For (validation year), Barangay (name of Barangay), achieved (Percentage) compliance with the terms of settlement or award
settlement or
after the case have been settled.
award after the
case have been i.e. For 2016, Barangay Putingkahoy, achieved 90% compliance with the terms of settlement or award after the case have
settled been settled.
 Kindly fill-out the information needed in the table.

 Attached at least 5 samples of proof of compliance.
MONITORING OF COMPLIANCE TO SETTLEMENT or AWARD

C46+ -Conciliation beyond 46
LEGEND: M-Mediation C-Conciliation A-Arbitration C w/ EP-Conciliation with Extendible Period
days
CASE TITLE ACTION
SETTLEMENT OR AWARD
(COMPLAINAN TAKEN MAIN POINT STATUS OF
CASE COMPLAINT
T (M, C, DATE DATE OF OF COMPLIANCE REMARKS
NO. TITLE
VS. Cw/EP, A AGREED EXECUTION AGREEMENT (C or NC)
RESPONDENT) and C46+)
2016- Juan Dela Cruz Collection of M January 28, February 5, 2016 Respondent C Respondent paid
01 vs. Juana Sum of 2016 agreed to pay Complainant the
Change Money Complainant amount of PhP
PhP 500.00 per 500.00 on:
month starting February 5,
February to March 6, April 7
pay for the and May 5, 2016.
total debt
amount of
PhP 2,000.00.
III. CREATIVITY AND RESOURCEFULNESS OF THE LUPONG TAGAPAMAYAPA

A. Settlement
Technique Describe the settlement technique used by the Lupong Tagapamayapa and explain briefly how each settlement technique
helps in the speedy settlement of disputes and attached two (2) photos with caption of application of each settlement
technique.
B. Coordination with  Please fill out the table provided with the information needed.
Concerned  Explain briefly how the Lupong Tagapamayapa coordinates with concerned agencies relating to disputes filed.
Agencies  A t t a c h p r o o f s o f
relating to disputes means of communication, two (2)
filed (PNP, DSWD, Photos with caption, Visitor's Log Book dated within the assessment period.
DILG, DAR,
DENR, Office of COORDINATION WITH AGENCIES
the Prosecutor, Date of Coordination Agency Coordinated Subject Matter Coordinated Proof of Coordination
Court/s, DOJ, CHR, June 15, 2016 MSWDO Case involving a child (Please attached here proof of
volunteer Coordination)
groups/organizatio
ns, NGOs, CSOs,
Barangay Justice
Advocates)
C. Sustained  Identify and briefly explain each information drive strategies practiced by the Lupong Tagapamayapa to create greater
information drive awareness to the community in promoting Katarungang Pambarangay (KP)
to promote  Attached two (2) photos with caption of the information drive used by the Lupong Tagapamayapa in the promotion of
Katarungang KP in their community.
Pambarangay
Note: Innovative Campaign Strategy Examples: Use of social media such as FB and other innovative strategies like
distribution of flyers, installation of tarpaulins or information board about KP.
D. Katarungang KP TRAINING or SEMINAR
Pambarangay
Training or
Seminar within the DATE TITLE OF THE TRAINING or SEMINAR VENUE SPONSOR/S PARTICIPANTS
Assessment Period April 14-15, 2016 Training on Gender-Responsive, Child-Friendly and 8th Floor Robredo DILG-RO Lupon Chairman, Lupon
Indigenous Peoples-Relevant Katarungang Hall, Quezon City Secretary and at least 2
1. Conducted by Pambarangay Lupong Tagapamayapa
members of all
the Barangay
Barangays in Quezon
City
2. Training
conducted by
government or
non-
government
organizations
Kindly fill-out the information needed in the table below. Provide brief explanation about the training and attached two (2)
participated by
photos with caption of each training conducted and attended.
Lupon members
First line is filled-out as guide.
IV. AREA OR FACILITY FOR KATARUNGANG PAMBARANGAY ACTIVITIES

Building structure or  Please describe briefly the building structure or space provided by the Barangay exclusively for KP and Lupong
space Tagapamayapa concerns and attach three (3) photos with caption.
Note: Area or Facility should have table and chairs to accommodate the parties and the Lupon and record book or computer
for documentation purposes. It should also have a filing cabinet/s where KP documents are maintained.
V. FINANCIAL OR NON-FINANCIAL SUPPORT
1. City,  Kindly fill-out the information needed in the table below. Explain briefly how the Lupong Tagapamayapa was able to
Municipal or acquire such grant from those provided in the criteria.
Provincial  Please attach proof of granting a support such as Deed of Donation, MOA, Resolution, Appropriation Ordinance of
Government
higher Sanggunian, Acknowledgment Receipt, Vouchers, etc.
and NGAs
2. People’s FINANCIAL OR NON-FINANCIAL SUPPORT

Organization, SUPPORT
NGOs or FINANCIAL NON-FINANCIAL DATE GRANTED/GIVEN DONOR/SPONSOR
Private Sector (Please provide the amount)
and others PhP 15,000.oo March 25, 2016 Gerry Roxas Foundation,
Inc.
1 Desktop set February 12, 2016 Quezon City Government
Prepared by: Approved by:
Lupon Secretary Lupon Chairman

Signature over Printed Name Signature over Printed Name
Verified by:
C/MLGOO
Signature over Printed Name Signature over Printed Name
LTIA FORM 07-A : LIST OF CASES
Punong Barangay
City/Municipality
Barangay Logo
Province Here
Region
LIST OF CASES
DATE OF STATUS OF
DATE OF
CAS DATE OF EXECUTION MAIN POINT COMPLIANCE
COMPLAINT DATE INITIAL ACTION
E CASE TITLE NATURE SETTLEMENT OF OF ON THE REMARKS
TITLE FILED CONFRON- TAKEN
NO. OR AWARD SETTLEMENT AGREEMENT SETTLEMENT
TATION
OR AWARD OR AWARD
2016- Juan Dele Collection Civil January January 25, M January 28, February 5, Respondent Complete Respondent paid
01 Cruz vs. of Sum of 22, 2016 2016 2016 agreed to pay Complainant the
Juana Money 2016 Complainant amount of PhP
Change PhP 500.00 per 500.00 on:
month starting February 5,
February to March 6, April 7
pay for the and May 5, 2016.
total debt
amount of
PhP 2,000.00.

Signature over printed name Signature over printed name
Date: ______________ Date: ______________
LTIA FORM 07-A : LIST OF CASES
Punong Barangay
City/Municipality
Barangay Logo
Province Here
Region
LIST OF CASES
DATE OF STATUS OF
DATE OF
CAS DATE OF EXECUTION MAIN POINT COMPLIANCE
COMPLAINT DATE INITIAL ACTION
E CASE TITLE NATURE SETTLEMENT OF OF ON THE REMARKS
TITLE FILED CONFRON- TAKEN
NO. OR AWARD SETTLEMENT AGREEMENT SETTLEMENT
TATION
OR AWARD OR AWARD

Signature over printed name Signature over printed name
Date: ______________ Date: ______________
LTIA FORM 07-B : LUPONG TAGAPAMAYAPA PROFILE

Punong Barangay
City/Municipality
Barangay Logo
Province Here
Region
LUPONG TAGAPAMAYAPA PROFILE
Photo of Lupon Photo of Lupon Photo of Lupon Photo of Lupon Photo of Lupon Photo of Lupon
Member here Member here Member here Member here Member here Member here
Name Name Name Name Name Name

Date of Birth Date of Birth Date of Birth Date of Birth Date of Birth Date of Birth
Terms of Office Terms of Office Terms of Office Terms of Office Terms of Office Terms of Office
Educational Background Educational Background Educational Background Educational Background Educational Background Educational Background
Photo of Lupon Photo of Lupon Photo of Lupon Photo of Lupon Photo of Lupon Photo of Lupon
Member here Member here Member here Member here Member here Member here
Name Name Name Name Name Name

Date of Birth Date of Birth Date of Birth Date of Birth Date of Birth Date of Birth
Terms of Office Terms of Office Terms of Office Terms of Office Terms of Office Terms of Office
Educational Background Educational Background Educational Background Educational Background Educational Background Educational Background

Punong Barangay
City/Municipality
Barangay Logo
Province Here
Region
Photo of Lupon Photo of Lupon Photo of Lupon Photo of Lupon Photo of Lupon Chairman here
Member here Member here Member here Member here
LUPON CHAIRMAN
Name Name Name Name Name
Date of Birth Date of Birth Date of Birth Date of Birth Date of Birth
Terms of Office Terms of Office Terms of Office Terms of Office Terms of Office
Educational Background Educational Background Educational Background Educational Background Educational Background
Photo of Lupon Photo of Lupon Photo of Lupon Photo of Lupon Photo of Lupon Secretary here
Member here Member here Member here Member here
LUPON SECRETARY
Name Name Name Name Name
Date of Birth Date of Birth Date of Birth Date of Birth Date of Birth
Terms of Office Terms of Office Terms of Office Terms of Office Terms of Office
Educational Background Educational Background Educational Background Educational Background Educational Background

Punong Barangay
City/Municipality
Barangay Logo
Province Here
Region

Group
Group Photo of the Lupong Tagapamayapa

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CY LUPONG TAGAPAMAYAPA INCENTIVES AWARDS (LTIA)

LTIA FORM 01-PERFORMANCE EVALUATION FORM

CRITERIA ASSIGNED POINT

II. EFFECTIVENESS IN SECURING THE SETTLEMENT OF 30

C. WE CERTIFY TO THE CORRECTNESS OF THE ABOVE INFORMATION.

2|LTIA FORM 01-PERFORMANCE EVALUATION FORM

B. CRITERIA AND PERFORMANCE RATING

CRITERIA ASSIGNED PERFORMANCE TOTAL AVERAGE

IV. AREA OR FACILITY 5

GRAND TOTAL POINT

C. WE CERTIFY TO THE CORRECTNESS OF THE ABOVE INFORMATION.

Member - ____________Awards Committee

5|LTIA FORM 02-CONSOLIDATED PERFORMANCE EVALUATION

B. COMPARATIVE EVALUATION RESULTS

LUPONG TAGAPAMAYAPA (LT) OVERALL ADJECTIVAL RANK

C. WE CERTIFY TO THE CORRECTNESS OF THE ABOVE INFORMATION.

6|LTIA FORM 03 [C/M]-COMPARATIVE PERFORMANCE

B. COMPARATIVE EVALUATION RESULTS

LUPONG TAGAPAMAYAPA (LT) OVERALL ADJECTIVAL RANK

C. WE CERTIFY TO THE CORRECTNESS OF THE ABOVE INFORMATION.

7|LTIA FORM 03 [P]-COMPARATIVE PERFORMANCE EVALUATION

B. COMPARATIVE EVALUATION RESULTS

LUPONG TAGAPAMAYAPA OVERALL ADJECTIVAL RANK

C. WE CERTIFY TO THE CORRECTNESS OF THE ABOVE INFORMATION.

8|LTIA FORM 03 [R]-COMPARATIVE PERFORMANCE EVALUATION

1. VALIDEE LT___________________ 1. VALIDEE LT______________________

4. WE CERTIFY TO THE CORRECTNESS OF THE ABOVE INFORMATION.

9|LTIA FORM 04-PERFORMANCE VALIDATION REPORT FORM

Highly Urbanized Cities Category ____________________________________

Please find the following enclosures:

Very truly yours,

Please find the following enclosures:

Very truly yours,

NATURE OF CASES ACTION TAKEN

***Total Number of Lupons excluding Lupon Chairman and Lupon Secretary

***Please attached Form 06-A “LIST OF CASES”

Unsettled Cases are defined as follows:

SETTLEMENT AND AWARD PERIOD

II. EFFECTIVENESS IN SECURING THE SETTLEMENT OF

Formula: Total Number of Settled Cases X 100

Please attach Form 7-A, List of Cases

 Kindly fill-out the information needed in the table.

MONITORING OF COMPLIANCE TO SETTLEMENT or AWARD

III. CREATIVITY AND RESOURCEFULNESS OF THE LUPONG TAGAPAMAYAPA

IV. AREA OR FACILITY FOR KATARUNGANG PAMBARANGAY ACTIVITIES

V. FINANCIAL OR NON-FINANCIAL SUPPORT

2. People’s FINANCIAL OR NON-FINANCIAL SUPPORT

Prepared by: Approved by:

Lupon Secretary Lupon Chairman

Prepared by: Approved by:

Lupon Secretary Lupon Chairman

Prepared by: Approved by:

Lupon Secretary Lupon Chairman

Name of the Lupong Tagapamayapa

LUPONG TAGAPAMAYAPA PROFILE

Name Name Name Name Name Name

Name Name Name Name Name Name

Name of the Lupong Tagapamayapa

LUPONG TAGAPAMAYAPA PROFILE

Name of the Lupong Tagapamayapa

LUPONG TAGAPAMAYAPA PROFILE

Group Photo of the Lupong Tagapamayapa

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1. VALIDEE LT_ 1. VALIDEE LT____