Form 1 -scc Republic of the Philippines MUNICIPAL TRIAL COURT IN CITIES 10% Judicial Region Branch __, Ozamiz City ‘o- Small Claims Case (SCC) No., For: COLLECTION OF SUM OF MONEY STATEMENT (Habla ng Pagsingil) 1. The personal circumstances of the parties are as follows: (Ang bawat panig ay ang mga sumusunod) (NAME OF PLAINTIFF/S) ~ (Sex) (Age) - (Civil Status) (Pangalan ng Naghahabla) (Kasarian) (Edad) —_(Katayuang Sibil) (Put a check on any of the following) (Pumili sa mga sumusunod at lagyan ng tsek) (1 individual (1 Corporation (2 Partnership (Tao/Indibidwal) (Korporasyon) (Bakasan) [7 Cooperative [7] Sole Proprietorship (Kooperatiba) (Solong Pagmamay-ari) NATURE OF BUSINESS: (Uri Ng Negosyo) {| Banking CG Lending C Others: Please indicate (Bangko) (Pagpapautang) (Iba Pang Uri ng Negosyo) PLAINTIFF'S HOME ADDRESS: (Pahatiran Ng Sulat sa Bahay ng Naghahabla) City: (Lungsod) (Province, if applicable): Zip Code: Telephone No. Cellphone No. PLACE OF WORK: Address: Zip Code: Telephone No. Cellphone No.NAME OF PLAINTIFF'S REPRESENTATIVE: (if applicable, must be a non lawyer) (Pangalan ng Kinatawan (dapat hindi abogado]) Home Adress: (City) Province: Telephone No. —_______________ Calliphone No. PLACE OF WORK: (Lugar na Pinagtatrabahuan) Telephone No. Cellphone No. NAME OF DEFENDANT (Sex) (Age) (Civil Status) _ (Pangalan ng Hinahabla) —(Kasarian) (Edad) + (Katayuang Sibil) (C1 Individual {JJ Corporation (7 Partnership (Tao/Indibidwal) (Korporasyon) (Bakasan) (Fj Cooperative — ([] Sole Proprietorship (Kooperatiba) (Solong Pagmamay-ari) DEFENDANT'S HOME ADDRESS: (Pahatirang Sulat sa Bahay ng Hinahabla) City: Zip Code: (Lungsod) (Province, if applicable): Zip Code: Telephone No. Cellphone No. PLACE OF WORK: _ Address: Telephone No. Cellphone No. If more than one (1) defendant, list next defendant here: | (Kung higit sa isa (1) ang hinahabla, ilagay ang susunod na hinahabla rito:) NAME OF DEFENDANT (Sex) (Age) (Civil Status) (Pangalan ng Hinahabla) (Kasarian) (Edad) (Katayuang Sibil) (1 Individual (71 Corporation 7 Partnership (Tao/Indibidwal) (Korporasyon) (Bakasan) (C1 Cooperative [7] Sole Proprietorship (Kooperatiba) (Solong Pagmamay-ari)DEFENDANT’S HOME ADDRESS: (Pahatirang Sulat sa Bahay ng Hinahabla) City: Zip Code: a : (Lungsod) ee (Province, if applicable): ee ee ee 5 Telephone No. picede Cellphone No. PLACE OF WORK: Address Telephone No, Cellphone No. NAME OF DEFENDANT'S REPRESENTATIVE: (if applicable, must be a non-lawyer) Mr./Ms./ (Pangalan ng Kinatawan) [dapat hindi abogado] Home Adress: (City) Zip Code: Province: Zip Code: Telephone No. Cellphone No. PLACE OF WORK: Address: (Lugar ng Pinagtatrabahuan) Telephone No. Cellphone No. * Note: if you need more space, you can write at the back of this Form. 2. Plaintiff claims the Defendant/s owes him/her/it the amount of: a ei ss aspen St sens scp Sse ss sepals sls popes sa snapenn ensues ESS (Ang Hinahabla ay umutang mula sa Naghahabla ng halagang) (a) Why does the Defendant owe Plaintiff money? (if more space is needed, please use the back page) (b) When did this happen? Date/Petsa: If no specific date, give the time period: Date Started: Through: (c) How did you compute the money owed to you? (Do not include Court costs or fees):S- (@) Did you ask the Defendant/s to pay you before you filed this case? (7 Yes (No IF No, explain: ee (b) How did you ask the Defendant? (In person (71 By phone [21 In writing (7 others (pls. specify) (¢) When did you do this? ee 4. What is your proof that Defendant/s owe you money? 5. Did you attach your proof to this form? J Yes (1 No 6. Was this claim referred to the Barangay? [J Yes [7] No [TJ Not Covered State reason: If Yes, do you have a Certificate to File Action or a Compromise Agreement Executed before the Barangay? [] Yes [=] No 6-A, How many Small Claims Case have you filed within this calendar year prior to this present case, in this Court Station and in the entire country? Answer: 7. By the filing of this action, Plaintiff waives any amount in excess of PhP300,000.00, excluding interest and costs. PRAYER (Pagsamo) WHEREFORE, plaintiff respectfully prays for judgment ordering herein Defendant/s to pay the amount of PhP. , with interest at the rate of % per annum/month from until fully paid. (PLAINTIFF) (Naghanabia) FOR OFFICIAL USE ONLY (To be accomplished by the Branch Clerk of Court) 1.) Cause of Action: 2) Bray. Conciliation Required (J Check If yes, Cert. to File Action [I Promissory Note Compromise Agreement Attached Contract: Brgy. Conciliation Not Required TL oral = 7 written (Please state the reason/s): (CJ Barangay Agreement = FE] Others (Please Specify)Form 1-A-SCC VERIFICATION and CERTIFICATION AGAINST NON-FORUM SHOPPING, SPLITTING A SINGLE CAUSE OF ACTION and MULTIPLICITY OF SUITS 1, of legal age, (name) (citizenship) (civil status) and a resident of , on oath state: 1. That I am the Plaintiff / Representative in the above-entitled case have caused this STATEMENT OF CLAIM for COLLECTION OF SUM OF MONEY to be prepared; that I read and understood its contents which are true and correct of my own personal knowledge and/or based on true records on file; 2. That I have not commenced any action or proceeding involving the same issue or subject matter, and specifically the same check/s in the Supreme Court, the Court of Appeals or any other tribunal or agency, particularly before the Office of the City Prosecutor; that to the best of my knowledge, no such action or proceeding Is pending in the Supreme Court , the Court of Appeals or any other tribunal or agency, and that, if I should learn thereafter that a similar action or proceeding has been filed or is pending before these Courts or Tribunal or Agency, I undertake to report that fact to the Court within five (5) days therefrom. 3. That the filing of this case is not in violation of the rule against splitting a single cause of action or multiplicity of suits. 4. That I knowingly and voluntarily waive and forego the institution of any criminal complaint for Violation of Batas Pambansa Big. 22 against the defendant herein based on the same check/s subject matter of this Small Claims Complaint. IN WITNESS WHEREOF, I have hereunto set my hand this (Affiant) SUBSCRIBED AND SWORN to before me this 5