Republic of the Philippines

MUNICIPALITY OF __________________
Province of Pangasinan
BARANGAY ______________

OFFICE OF THE LUPONG TAGAPAMAYAPA

_________________________ Brgy. Case No. ___________

_________________________ For ____________________
Complainant/s ____________________
-against- ____________________

_________________________
_________________________
Respondent/s

CERTIFICATION OF FILE ACTION

This is to certify that:

1. There was a personal confrontation between the parties before the Punong
Barangay but mediation failed;
2. Therefore, the corresponding complaint for the dispute may now be filed in
court/government office.

________________________
Barangay/Lupon Secretary

Attested:

____________________________
Punong Barangay/Lupon Chairman