REPUBLIC OF THE PHILIPPINES )

CITY OF CATBALOGAN ) S.S.

AFFIDAVIT

I, JULIET M. DONAIRE, of legal age, married and presently residing at

Barangay Sto. Nio, Villareal, Samar, after having been duly sworn to in
accordance with law, hereby depose and say that:

1. I am the Punong Barangay of Barangay Sto. Nio, Vilareal,

Samar;

2. There has been a personal confrontation between Guida

Pelareja and Zosimo Tan last September 5, 2017 but mediation
failed;

3. No settlement was reached after such personal confrontation;

4. Since no settlement was reached, my office was under the

responsibility to issue a CERTIFICATION TO FILE ACTION, which was
needed before a case would be filed in court;

5. We failed to issue such certification to the parties;

6. The reason for such failure is because we lack the necessary

forms to issue a CERTIFICATION TO FILE ACTION when the
personal confrontation took place;

7. It is only now that we are able to produce such certification to

the parties;

8. I am executing this affidavit to attest to the truth of the

foregoing facts.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

______ DAY of NOVEMBER 2017 at CATBALOGAN CITY, SAMAR.

JULIET M. DONAIRE
AFFIANT

SUBSCRIBED AND SWORN to before me this ________ day of

NOVEMBER 2017 at Catbalogan City, Samar.

Doc. No. ________

Page No. _______
Book No. ________
Series of 2017