KP FORM # 4: LIST OF APPOINTED LUPON MEMBERS

Republic of the Philippines

Province of __________
CITY/MUNICIPALITY OF ______________
Barangay _________________
OFFICE OF THE PUNONG BARANGAY

_________, 20
____

LIST OF APPOINTED LUPON MEMBERS

Listed hereunder are the duly appointed members of the Lupong Tagapamayapa in this Barangay
who shall serve as such upon taking their oath of office and until a new Lupon is constituted on
the third year following their appointment.

1. _________________ 11. _________________

2. _________________ 12. _________________
3. _________________ 13. _________________
4. _________________ 14. _________________
5. _________________ 15. _________________
6. _________________ 16. _________________
7. _________________ 17. _________________
8. _________________ 18. _________________
9. _________________ 19. _________________
10. ________________ 20. _________________

_______________
Punong Barangay

ATTESTED:
______________________
Barangay/Lupon Secretary

IMPORTANT: The list shall be posted in three (3) conspicuous places in the barangay for the
duration of the terms of office of those named above.

WARNING: Tearing or defacing this notice shall be subject to punishment according to law.