Sample Form - Certification to file Action from Barangay

Republic of the Philippines

Province of _____

CITY OF ______

Barangay ______

OFFICE OF THE LUPONG TAGAPAMAYAPA

Barangay Case No. 2010-005

For: Collection of Sum of Money

Mr. B                                                            

Complainant                                                 

— against —

Mr. A

Respondent

CERTIFICATION TO FILE ACTION

This is to certify that:

1. There has been a personal confrontation between the parties before the

Punong Barangay/Pangkat ng Tagapagkasundo;

2. A settlement was reached;

3. The settlement has been repudiated in a statement sworn to before the

Punong Barangay by Mr. B on ground of non- fulfillment of Mr. A to pay the principal amount plus interest on the day agreed upon in the settlement; and (state the reason)

4. Therefore, the corresponding complaint for the dispute may now be filed in

Court.

This 26^th  day of December, 2010 at ________, Philippines.

Mrs. Myrna Natividad

Lupon Secretary

Attested:

Brgy. Captain Vincente Roxas

Lupon Chairman

Civil Code of the Philippines: With special laws