KP Form No.

21

Republic of the Philippines

Province of Pampanga
Municipality of Guagua
Barangay San Nicolas 2nd Betis

OFFICE OF THE LUPONG TAGAPAMAYAPA

Mrs. Anita Gozum Serrano Barangay Case No. ____________________

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

Mr. Rodolfo Gozum

-and-
Ms. Caridad Gozum
San Nicolas 2nd Betis Guagua, Pamp.
Respondent/s

CERTIFICATION TO BAR ACTION

This is to certify that the above-captioned case was dismissed pursuant to the
Order dated June 07, 2019(Friday), for complainant/s Mrs. Anita Gozum Serrano
(name) willfully failure or refusal to appear for hearing before the Punong
Barangay/Pangkat ng Tagapagkasundo and therefore complainant/s is/are barred from
filing an action in court/government office.

This _________ day of ___________________, 20_______.

_____________________________
Lupon Secretary/Pangkat Secretary

Attested:

__________________________
Lupon Chairman/Pangkat Chairman

IMPORTANT: If Lupon Secretary makes the certification, the Lupon Chairman attests. If the
Pangkat Secretary makes the certification, the Pangkat Chairman attests.