KP Form No.

Republic of the Philippines

Province of Camarines Sur
Municipality of Nabua
Barangay SAN ROQUE POBLACION

OFFICE OF THE LUPONG TAGAPAMAYAPA

_______________________________ Barangay Case No.: 201___-__________

_______________________________ For: ______________________________
Complainant/s ______________________________
- against - ______________________________
_______________________________
_______________________________
Respondent/s

C O M P L A I N T

I/WE hereby complain against above named respondent/s for violating my/our rights
and interests in the following manner:

_____________________________________________________________________________________
___________________________________________________________________________________________
____________________________________________________.

THEREFORE, I/WE pray that the following relief/s be granted to me/us in accordance
with law and/or equity.

_____________________________________________________________________________________
___________________________________________________________________________________________
____________________________________________________.

Made this _______ day of ___________________, 201__.

______________________________
(Complainant/s)

Received and filed this __________ day of ___________, 201___.

HON. IMELDA V. BOLIVAR

Punong Barangay/Lupon Chairman