Republic of the Philippines

City of Manila
Barangay ______
OFFICE OF THE BARANGAY CAPTAIN
_________________________,
Complainant,
- versus -

Barangay Case No. _______________

For: ___________________________

__________________________,
Respondent.
x ------------------------------------------------------------------------------------ x
CERTIFICATE TO FILE ACTION
This is to certify that:
Complainant ________________________ (name) and respondent ________________________
(name) failed to or refuse to:
_______ Obey summons or to appear for hearing
_______ No settlement/conciliation was reached
_______ Settlement has been repudiated
And therefore, the corresponding complaint between the parties may now be filed in
court/government office concern.
This ___ day of ___________, 200__.
________________________________
Lupon/Pangkat Secretary
ATTESTED BY:
___________________________
Lupon/Pangkat Chaiman