KP Form No.

22
Republic of the Philippines
Province of Pampanga
Municipality of Guagua
Barangay San Nicolas 2nd Betis

OFFICE OF THE LUPONG TAGAPAMAYAPA

Mrs. Anita Serrano Barangay Case No. KP001-2019

San Nicolas 2nd Betis, Guagua, Pamp For: ________________________
Complainant/s

-Against-

Mr. Rodolfo Gozum

And
Mrs. Caridad Gozum
San Nicolas 2nd Betis
Guagua, Pampanga
Respondent/s

CERTIFICATION TO BAR COUNTERCLAIM

This is to certify that after prior notice and hearing, the respondent/s Mr. Rodolfo
Gozum and Ms. Caridad Gozum have been found to be willfully failed or refused to
appear without justifiable reason before the Punong Barangay/Pangkat ng
Tagapagkasundo and therefore respondent/s is/are barred from filing his/their
counterclaim (if any) arising from the complaint in court/government office.

This _________ day of ___________________, 20_______.

_____________________
Pangkat Secretary

Attested:

________________________ ________________________
Pangkat Chairman Pangkat Member