KP Form No.

Republic of the Philippines

Province of Zambales
Municipality of Subic
Barangay Ilwas

OFFICE OF THE LUPONG TAGAPAMAYAPA

__________________________________ Barangay Case No. _______________

__________________________________ For: ____________________________
Complaiantn/s

-against/s –

__________________________________
__________________________________
Respondent/s

SUMMON

TO: ______________________________ ________________________________

__________________________________ ________________________________
Respondent/s

You are hereby summoned to appear before me in person, together with your witnesses,
on the _________________ day of _____________________, 2008, at ________
O’clock in the ___________________, then and there to answer to a complaint made before me,
copy of which is attached hereto, for mediation/conciliation of your dispute with complainants.

You are hereby warned that if you refuse or willfully fail to appear in obedience to this
summon, you may be barred from filing any counterclaim arising from said complaint.

FAIL NOT or else face punishment as for contempt of court.

This__________________ day of ________________, 2008.

ARIEL R. APOSTOL
Punong Barangay/Lupon Chairman

KP Form No. 9
Page 2

OFFICER’S RETURN
 I served this summons upon respondent ______________________________ on the
________ day of _________________, 2008, and upon respondent ____________________ on
the ______________ day of _______________, 2008, by: (Write name/s of respondent/s before
mode by which he/they was/were served.)

Respondent/s

___________________________________ 1. handing to him/them said summons in

___________________________________
or
___________________________________
___________________________________
person or
2. handing to him/them said summons
and he/they refused to receive it,
3. leaving said summons at his/their
dwelling with ______________________
(Name)
A person of suitable age and discretion
residing therein, or
4. leaving said summons at his/their
office/place of business with
__________________________________
(Name)
a competent person in charge thereof.

__________________________________

__________________________________
__________________________________

Officer

Received by Respondent/s/representative/s:

____________________________________ ____________________________________
Signature Date

____________________________________ ____________________________________
Signature Date