Republic of the Philippines

Province of LA Union
Municipality of Caba
BARANGAY URAYONG

OFFICE OF THE PUNONG BARANGAY

BARANGAY CLEARANCE
Name:___________________________________________
Address:_________________________________________
Sex:__________ Age:_____Civil Status:________________

TO WHOM IT MAY CONCERN:

This is to certify that the above-named person whose signature and
thumbmarks appear below is a bonafide resident of this Barangay.

It is further certified that he/she is a law-abiding citizen and not known to be a

member of any subversive organization or fugitive from justice and has no pending
case filed against him/her per records now available in our Barangay Office as of this
date.

PURPOSE:_____________________________
DATE ISSUED:_________________________

__________________________
(Signature)

THUMBMARKS

CTC No. ________________________________________________

Issued On:______________________________________________
Issued At:_______________________________________________

LEFT RIGHT

Paid under O.R. No.________________________________

Amount Paid: ________________________________ HON. SAMUEL R.
CAMACHO
On ________________________________ Punong Barangay
Issued At ________________________________

DST PAID

“Not valid without Barangay Official dry seal”