Republic of the Philippines

Province of the Nueva Ecija

Municipality of Sta. Rosa
Barangay Rizal

OFFICE OF THE BARANGAY CAPTAIN

BARANGAY CLEARANCE

To whom it may concern:

THIS IS TO CERTIFY THAT _________________________________________, ___years of

age, male/female, with residence and postal address at Barangay Rizal, Sta. Rosa, Nueva Ecija and
with the Residence Certificate NO. ________, is personally know to me and know to be good moral
character reputation.

THIS IS FURTHER CERTIFIED that the subject has never been convicted of any crime nor
has pending case field against him/her in any court of justice in Barangay Municipality.

GIVEN AND SIGNED THIS _____ day of ________________, 20___ at Barangay Rizal,
Sta. Rosa, Nueva Ecija Philippines.

THIS BARANGAY CLEARANCE IS NOT VALID WITHOUT SEAL.

VANESSA ANN BALANI

_________________________ Barangay Secretary
Applicant Signature

GIL T. DE LEON
Barangay Captain

Left Right

PURPOSE: ________________________________
NOTE: This Barangay Clearance is good until 90 days only after issue.
Serial No. ________