Sunday, March 13, 2011

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



Mrs. Myrna Natividad
Lupon Secretary



Attested:


Brgy. Captain Vincente Roxas
Lupon Chairman



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