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.”