BJ Form No.

10-D

REPUBLIC OF THE PHILIPPINES

CITY OF MANILA
BARANGAY _________, ZONE _____, DISTRICT_____

OFFICE OF THE LUPON TAGAPAMAYAPA

_____________________________ Barangay Case No. _____________

_____________________________ For: _________________________
Complainant/s,

-againts-

_____________________________
_____________________________
Respondent/s.

x-- -- -- -- -- -- -- -- -- -- -- -- -- -- x

CERTIFICATION TO BAR COUNTERCLAIM

This is to certify that after prior and hearing, herein respondent/s

____________________________(name) and ____________________________(name)
willfully failed to refused to appear without justifiable reason before the Punong
Barangay for the constitution of the Pangkat ng Tagapagkasundo and therefore
respondent/s is/are BARRED from filing their counterclaim (if any) arising from the
complaintin court/government office.

This _______ day of __________, 201___ at the City of Manila.

____________________________________
Punong Barangay/Lupon Chairman