KP FORM NO.

Republic of the Philippines

Province of _____________________
CITY/MUNICIPALITY OF _________________
Barangay ________________________

OFFICE OF THE PUNONG BARANGAY

____________________, 20____
(Date)

APPOINTMENT

TO: _______________________

Pursuant to Chapter 7, Title One Book III, Local Government Code

of 1991 (Republic Act No. 7160), you are hereby appointed MEMBER of
the Lupon Tagapamayapa of this Barangay effective upon taking your oath
and until a new Lupon is constituted on the third year following your
appointment.

___________________________
Punong Barangay

ATTESTED:

________________________
Barangay Secretary