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Republic of the PhilippinesMunicipality of ___________________
Province of ________________BARANGAY ________________
OFFICEOF THE PUNONG BARANGAY
CERTIFICATE OF INDIGENCE
TO WHOM IT MAY CONCERN:
This is to certify that _____________________________________, of legal age,male/female, single/married/widow/widower, Filipino citizen, with residence at No. ____,_________________ Street, Barangay ________________, this City/Municipality, whosespecimen signature appears below, is an INDIGENT and has no means of income.
This certification is being issued upon the request of the above-named person forwhatever legal purpose it may serve him/her.
Issued this ____ day of _____________ 20____ at Barangay _______________,___________, _____________, Philippines.
Specimen Signature:
__________________________
__________________________Punong Barangay
Amount Paid: _________O.R. No. _____________Date: ________________
“Not valid without official seal. Not valid without official receipt.”