KP Form No.

Republic of the Philippines

Province of Leyte
Municipality of Javier
Barangay Pob. Zone II

OFFICE OF THE LUPONG TAGAPAMAYAPA

LOLITA MAICO
MADELYN LUENBURGER Barangay Case No. 1
Complainant/s For: Civil Case
January 14, 2024
-against- 10:00 am

BARNARDITA GARCIA
Respondent/s

SUMMON
TO: BARNARDITA GARCIA ;

Respondents

You are hereby summon to appear before me in person, together with your witnesses, on the 15th
day of February 2024, at (10:00) ten o’clock in the morning/afternoon, then and there to answer to a
complaint made before me, copy of which is attached hereto, for mediation/conciliation of your dispute
with complaint.

You are hereby warned that if you refuse or willfully fail to appear in obedience to this summons,
you may be banned from filling any counterclaim arising from said complaint.

FAIL NOT or else face punished as for contempt of court.

This 14th day of February, 2024.

REY A. ABALOS
Punong Barangay
 KP Form No. 9

Republic of the Philippines

Province of Leyte
Municipality of Javier
Barangay ___________

OFFICER’S RETURN

This summon is upon request of __________________________________ on the ______

day of _________________, 2024 and upon respondent ____________________________
on the _________________ day of, ________________, 20____, by;

Respondent/s

___________________________ 1. handling to him/them said summons in

___________________________ 2. handling to him/them said summons and
____________________________ 3. leaving said summons at his/their dwelling with

______________________________
name
a person of suitable age and discretion residing therein, or
_____________________________ 4. Leaving said summons at his/their office/place of business with

______________________________
name
A counterpart pertains in charge thereof.

_______________________________________
Officer

Receive by Respondents representative

________________________________ _______________________________
(Signature) (Date)

________________________________ _______________________________
(Signature) (Date)