Katarungang Pambarangay Form No.

21

Republic of the Philippines

Province of ________________
City / Municipality of ________
Barangay __________________

OFFICE OF THE LUPONG TAGAPAMAYAPA

_________________________________
_________________________________
Complainant/s Barangay Case No.
______________
For: ________________________
________________________
________________________
_________________________________
_________________________________
Respondent/s

CERTIFICATION TO BAR ACTION

This is to certify that the above – captioned case was dismissed

pursuant to the Order dated ________________ , for complainant/s
___________________ and ________________ willful failure or refusal to
appear for hearing before the Punong Barangay / Pangkat ng
Tagapagkasundo and therefore complainant/s is/are barred from filling
an action in court / government office.

This _________ day of ________________ , 20 ____ .

______________________________
Lupon Secretary / Pangkat Secretary

ATTESTED:

________________________________
Lupon Chairman / Pangkat Chairman