Republika ng Pilipinas

LALAWIGAN NG RIZAL

Road A Phase IV COGEO Village, Barangay Bagong Nayon, Antipolo City 1870 Rizal, Philippines
 barangay_bagongnayon@yahoo.com   647-0942   942-0358   bagongnayon.antipolo@gmail.com
www.facebook.com/BagongNayonOfficialPage   www.antipolo.ph

KP PORMULARYO BLG. 23

BARANGAY CASE NO. _______________

____________________________
COMPLAINANT/S
____________________________
____________________________
(Address)

AGAINST: FOR:

____________________________ ____________________________________
RESPONDENT/S
____________________________ ____________________________________
Barangay Bagong Nayon,Antipolo City
(Address)

CERTIFICATION TO BAR ACTION

This is to certify that the above-captioned case was dismissed pursuant to the Order
dated ______________, for complainant/s _______________ (name) and
______________ (name) willful failure or refusal to appear for hearing before the
Punong Barangay/Pangkat ng Tagapagkasundo and therefore complainant/s is/are
barred from filing an action in court/government office.

This _________ day of __________, 20____.

_________________________
Lupon Secretary/Pangkat Secretary

Attested:

__________________________
Lupon Chairman/Pangkat Chairman

IMPORTANT: If Lupon Secretary makes the certification, the Lupon Chairman attests. If the
Pangkat Secretary makes the certification, the Pangkat Chairman attests.

Barangay Bagong Nayon: Kabalikat sa Kaunlaran at Pagbabago ng Lungsod ng Antipolo.