KB Form No.

15 Appendix “D”- 14

Republic of the Philippines

Province of Eastern Samar
Municipality of Arteche
Barangay Garden

OFFICE OF THE PUNONG BARANGAY

_________________________ Barangay Case No.

_________________________ For: ____________________________________
Complainant/s ____________________________________
____________________________________
Against

_________________________
_________________________
Respondent/s

CERTIFICATE TO BAR ACTION/COUNTERCLAIM

This is to certify that the above-caption case was dismissed for:

(Cross out which is not applicable)

Complainant/s _______________________________________________ and

(name)
_________________________________________________ willful failure or
(name)
refusal to appear for hearing.

Respondent/s _______________________________________________ and

(name)
_________________________________________________ willful failure or
(name)
refusal to appear for hearing.

and therefore complainant/s or respondent/s is/are barred from filling an action

or counterclaim, respectively, in court/government office.

This _______ day of ________, 2019.

________________________________
Lupong/Pangkat Secretary
Attested:

_______________________________
Lupon/Pangkat Chairman