BJ Form No.

20-B

REPUBLIC OF THE PHILIPPINES

CITY OF MANILA
BARANGAY _________, ZONE _____, DISTRICT_____

OFFICE OF THE LUPON TAGAPAMAYAPA

_______________________ Barangay Case No. ________

_______________________ For: ____________________
Complaint/s,

-against-

______________________
______________________
Respondent/s.

X-- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- x

CERTIFICATION TO FILE ACTION

This is to certify that:

1. There was a personal confrontation between the parties before the Punong
Barangay but mediation failed;

2. The Punong Barangay set the meeting of the parties for the constitution of the
Pangkat;

3. The respondent willfully failed or refused to appear without justifiable reason at

the conciliation proceedings before the Pangkat;

Therefore, the corresponding complaint for the dispute may now be filed in
court/government office.

__________________________
Lupon Secretary

ATTESTED BY:

__________________________
Pangkat Chairman