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Katarungang Pambarangay Handbook_0

KP FORM # 17:

KP FORM # 17: REPUDIATION Republic of the Philippines Province of __________ CITY/MUNICIPALITY OF ______________ Barangay _________________ OFFICE OF THE LUPONG TAGAPAMAYAPA ___________________ Barangay Case No. __________ ___________________ For: ______________________ Complainant/s _________________________ __________________________ — against — __________________ __________________ Respondent/s R E P U D I A T I O N I/WE hereby repudiate the settlement/agreement for arbitration on the ground that my/our consent was vitiated by: (Check out whichever is applicable) [ ] Fraud. (State details) _______________________________ ________________________________________________ ________________________________________________ [ ] Violence. (State details)______________________________ ________________________________________________ ________________________________________________ [ ] Intimidation. (State details) ___________________________ ________________________________________________ ________________________________________________ This ________ day of _____________, 19____. Complainant/s ___________________ ___________________ Respondent/s __________________ __________________ SUBSCRIBED AND SWORN TO before me this ________ day of __________, 19____ at _____________. 100 A HANDBOOK

_____________________________________ Punong Barangay/Pangkat Chairman/Member Received and filed * this ______ day of ______________, 19_____. ____________________ Punong Barangay * Failure to repudiate the settlement or the arbitration agreement within the time limits respectively set (ten [10] days from the date of settlement and five[5] days from the date of arbitration agreement) shall be deemed a waiver of the right to challenge on said grounds. KATARUNGANG PAMBARANGAY 101

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