Office of the Lupong Tagapamayapa

Interview Questionnaire (Form 01B-2019)

Barangay Salvacion, Bula, Camarines Sur
Barangay Case No. 26 – Collection for Sum of Money Scheduled Date/Time: July 26, 2019 / 9:00 AM
PSSG RICARDO C. PALACIO vs JUSTINA E. ANTIOQUIA
Complainant Respondent
A Brief Situational Account (Summary lifted from the Complainant/Respondent. Use extra sheet if needed)

Checklist on Due process YES NO

Did you receive a Notice for your appearance in this forum (Lupon)?
Were you informed or in full knowledge of the purpose of this forum?
Did you come or appeared to this forum on your own Free will? *
If not, describe the circumstance of your appearance.
Complainant: Have you written and submitted a statement of your complaint to the forum?
Respondent: Have you written and submitted a statement to indicate your side surrounding the
complaint to the forum?
Do you pledge to cooperate in seeking for the Truth and tell nothing but the Truth all throughout the
proceedings?
Results of the Interview
Particular agreements and conditions: Lifted from an Authenticated copy

Amounts involved Total Amount: Settled: Unsettled:

and description of circumstances surrounding settlements/ failure to settle as stipulated in the statement of
agreement and conditions.

Documents presented as evidence: (Authenticated copies will suffice)

Prayer by complainant:

Respondent:

New proposals and agreements

Remarks: (e.g. Agreed dates of succeeding hearings, dates to settle, etc.)

Results of Conciliation

Recommendations:

Signatories:

Pangkat Member Punong Barangay

Office of the Lupong Tagapamayapa
Situational Account / Incident Report – Complainant/Respondent (Form 01A-2019)
Barangay Salvacion, Bula, Camarines Sur

YES NO
Did you receive a Notice for your appearance in this forum (Lupon)?
Were you informed or in full knowledge of the purpose of this forum?
Did you come or appeared to this forum on your own Free will?
If not, describe the circumstance of your appearance. * (Write below)
Do you pledge to cooperate in seeking for the Truth and Tell nothing but the truth all throughout
the proceedings?

Signature: Attested by: