Republic of the Philippines

City of Zamboanga
Barangay ___________________

OFFICE OF THE LUPONG TAGAPAMAYAPA

Complainant/s
Barangay Case No. ____________________
______________________________
For: ______________________________
-against-

________________________________
Respondent/s

CERTIFICATION TO BAR ACTION

This is to certify that the above-captioned case was dismissed pursuant to the Order dated
__________________, for complainant/s ______________________ (name) and
_________________________ (name) willful 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/Pangkat Secretary

Attested by:

___________________________
Lupon/Pangkat Chairman