KP Form No.

16

Republic of the Philippines

Province of _______________________
City/Municipality of ________________
Barangay _________________________

OFFICE OF THE LUPONG TAGAPAMAYAPA

___________________ Barangay Case No. _______________

___________________ For: ____________________
Complainant/s ___________________
-against- ____________________

_________________
_________________
Respondent/s

AMICABLE SETTLEMENT

We, complainant/s and respondent/s in the above-captioned case, do hereby agree to

settle our dispute as follows:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________

and bind ourselves to comply honestly and faithfully with above terms of settlement.

Entered into this _______ day of ______________,20 _____.

Complainant/s Respondent/s

______________________ ________________________
______________________ ________________________

ATTESTATION

I hereby certify that the foregoing amicable settlement was entered into by the parties freely
and voluntarily, after I had explained to them the nature and consequence of such settlement.

_______________________________
Punong Barangay/ Lupon Chairman