Republic of the Philippines

Province of Agusan del Norte

Municipality of ______________
OFFICE OF THE PUNONG BARANGAY
Barangay ___________

CERTIFICATION
Date: _______/___/20__

TO WHOM IT MAY CONCERN:

This is to certify that the Mr/Ms/Mrs ____________________ is a resident of this

barangay for the last ____yrs and ____ months and the following information
provided by him/her are correct to the best of my knowledge and belief.

Name of Child
First Name :_________________________
Middle Name :_________________________
Last Name :_________________________
Ext Name :_________________________

Sex :_________________________
Date of Birth :_________________________
Place of Birth :_________________________
Mother’s Maiden Name
First Name :_________________________
Middle Name :_________________________
Last Name :_________________________
Ext Name :_________________________

Name of Father
First Name :_________________________
Middle Name :_________________________
Last Name :_________________________
Ext Name :_________________________

Date of Marriage of Parents :_________________________

Place of Marriage of Parents :_________________________

This certificate is hereby issued for the purpose of UPDATING THE CHILD AS
ADDITIONAL MEMBER IN THE 4PS RECORD only.

_____________________________
Name & Signature of Parent Leader Date signed: ______________

_______________________________
Name & Signature of Barangay Captain Date signed: ______________