Katarungang Pambarangay Form No.

17

Republic of the Philippines

Province of _______________
City / Municipality of _______
Barangay _________________

OFFICE OF THE LUPONG TAGAPAMAYAPA

_________________________________
_________________________________
Complainant/s Barangay Case No. ________
For: _________________
_________________
_________________
_________________________________
_________________________________
Respondent/s

REPUDIATION

I/WE hereby repudiate the settlement / agreement for arbitration on the

ground that my /our consent was vitiated by:

(Check out whichever is applicable)

- Fraud. (State details)

_______________________________________________
___________________________________________________________

- Violence. (State details)

___________________________________________
___________________________________________________________
 - Intimidation. (State details)
__________________________________________
___________________________________________________________

This _________ day of ________________ 20 ______ .

Complainant/s: Respondent/s:

_______________________ _______________________
_______________________ _______________________
_______________________ _______________________

SUBSCRIBED AND SWORN TO before me this _____ day of

__________ , 20 _____ at ________________ .

____________________________
Punong Barangay /
Pangkat Chairman / Member

Received and filed * this ______ day of __________ 20 ______ .

____________________________
Punong Barangay

* Failure to repudiate the settlement or the arbitration agreement within the

time limits respectively set ten (10) days from date of settlement and five (5) days
from date of arbitration agreement ] shall be deemed a waiver of the rights to
challenge on said grounds.