Republic of the Philippines

Province of ______________
Municipality of ______________
Barangay ___________
CERTIFICATE TO FILE ACTION
This is to certify that complainant _____________________ and defendant
___________________ underwent barangay conciliation in this office. There were several
meetings held to amicably settle the issue on _________________________, however, no
agreement was reached by the parties except to elevate the matter to court.
[If the defendant refuses to appear, use this instead: This is to certify that
complainant _____________________ had requested this office to help him/her amicably settle
with defendant ___________________. However, the defendant refused to appear for at least
two scheduled meetings.]
This certificate is issued on ______________________ upon the complainant's request as a
condition precedent for the filing of action in court.
______________________
(Signature over printed name of Barangay Captain or Presiding Officer of Lupon)
Date: ______________________