Small Claims Form

A.M. No.
08-8-7-SC
FORM 1-SCC
REPUBLIC OF THE PHILIPPINES

FOURTH JUDICIAL REGION
MUNICIPAL TRIAL COURT

SANTA CRUZ, LAGUNA
__DORIS CAMARILLO,__________
__represented by LAARNI CAMARILLO,
Plaintiff/s,
vs.
____________________________
__NORVIE PABILONIA,________
_______________________________________
____________________________________,
Defendant/s.
x- - - - - - - - - - - - - - - - - - - - - - - -x
Civil Case No.

For:
STATEMENT OF CLAIM
(HABLA NG PAGSINGIL)
Plaintiff respectfully alleges:
(Ang naghahabla ay magalang na nagsasaad:)
1. The personal circumstances of the parties are as follows:
(Ang bawat panig ay ang mga sumusunod)
___DORIS CAMARILLO___
_________________
NAME OF PLAINTIFF/S
(Pangalan ng Naghahabla)
(Katayuang Sibil)
INDIVIDUAL
(Tao/Indibidwal)
COOPERATIVE
(Kooperatiba)
PAGE 1 OF 5
HOME ADDRESS:
CRUZ____ __4009___
(Pahatirang Sulat)
(Zip Code)
_FEMALE_ ______
SEX
(Kasarian)
CORPORATION
(Korporasyon)
AGE
CIVIL STATUS
(Edad)
PARTNERSHIP
(Bakasan)
SOLE PROPRIETORSHIP
(Solong Pagmamay-ari)
(Town/City) _______BRGY._SAN JOSE, SANTA

(Bayan/Lungsod)
(Province, if applicable)
__________________LAGUNA_____________________
(Lalawigan, king meron)
(Zip Code)
___4009____
Telephone No. ____________________________

Cellphone No.
_______0929-253-3249__
(Telepono Blg.)
(Selpon Blg.)
PLACE OF WORK
__________________________________________________________________________________
(Lugar ng Pinagtatrabahuhan)
NAME OF REPRESENTATIVE, if applicable _________LAARNI

CAMARILLO_________________
(Pangalan ng Kinatawan, kung meron)
HOME ADDRESS:
CRUZ____________________
(Pahatirang Sulat)
(Zip Code)
(Town/City) ______BRGY. SAN JOSE, SANTA

(Bayan/Lungsod)
____________LAGUNA___________________________ ______________
(Lalawigan, kung meron)
(Zip Code)
Telephone No. ____________________________
Cellphone No.
_____________________________
(Telepono Blg.)
(Selpon Blg.)
______________________________
_________________
NAME OF DEFENDANT/S
(Pangalan ng Hinahabla)
(Katayuang Sibil)
INDIVIDUAL
(Tao/Indibidwal)
COOPERATIVE
(Kooperatiba)
______
SEX
(Kasarian)
_____
AGE
CIVIL STATUS
(Edad)
CORPORATION
PARTNERSHIP
(Korporasyon)
(Bakasan)
SOLE PROPRIETORSHIP
HOME ADDRESS:
(Town/City)
_______________________________________________
(Pahatirang Sulat)
(Bayan/Lungsod)
(Zip Code)
_________________________________________________
(Zip Code)
_____________
______________
Telephone No. ____________________________

Cellphone No.
_____________________________
(Telepono Blg.)
(Selpon Blg.)
PAGE 2 OF 5
PLACE OF WORK
__________________________________________________________________________________
NAME OF REPRESENTATIVE, if applicable
____________________________________________________
HOME ADDRESS:
(Town/City)
_______________________________________________
(Pahatirang Sulat)
(Bayan/Lungsod)
(Zip Code)
_________________________________________________
_____________
______________

(Zip Code)
Telephone No. ____________________________
Cellphone No.
_____________________________
(Telepono Blg.)
(Selpon Blg.)
If there are 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/S
(Pangalan ng Hinahabla)
(Katayuang Sibil)
INDIVIDUAL
(Tao/Indibidwal)
COOPERATIVE
(Kooperatiba)
______
SEX
(Kasarian)
_____
AGE
CIVIL STATUS
(Edad)
CORPORATION
PARTNERSHIP
(Korporasyon)
(Bakasan)
SOLE PROPRIETORSHIP
HOME ADDRESS:
(Town/City)
_______________________________________________
(Pahatirang Sulat)
(Bayan/Lungsod)
(Zip Code)
_________________________________________________
(Zip Code)
_____________
______________
Telephone No. ____________________________

Cellphone No.
_____________________________
(Telepono Blg.)
(Selpon Blg.)
PLACE OF WORK
__________________________________________________________________________________
NAME OF REPRESENTATIVE, if applicable
____________________________________________________
PAGE 3 OF 5
HOME ADDRESS:
(Town/City)
_______________________________________________
(Pahatirang Sulat)
(Bayan/Lungsod)
(Zip Code)
_________________________________________________
(Zip Code)
_____________
______________
Telephone No. ____________________________

Cellphone No.
_____________________________
(Telepono Blg.)
(Selpon Blg.)
(*NOTE: If you need more space, you can write at the back of this Form.)
(*Tala: Kung kailangan ng karagdagang patlang, maaaring isulat sa likod ng Form

na ito.)
2. Plaintiff claims the defendant
owes PHP
___________________________________
__. (Ang hinahabla ay umutang sa
Naghahabla ng halagang
PHP_______________________________
______.)
(a). Why does the defendant/s
owe
plaintiff/s money?
(Bakit ang Hinahabla ay
nagkautang
ng salapi sa Naghahabla?)
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
_________________________
(b). When did this happen?
(Kailan ito nangyari?)
Date:
___________________________________
_
(Petsa)
PAGE 4 OF 5
If no specific date, give the

time
period:
(Kung walang tiyak na petsa,
ibigay
ang tantiyang panahon)

Date started:
___________________________
(Petsa ng nagsimula)
Through:
_______________________________
(Hanggang)
FOR OFFICIAL USE ONLY
(Para sa Opisyal na gamit
lamang)
- To be accomplished by the Branch Clerk
of Court
1. CAUSE OF ACTION
Check
Promissory Note
Contract
Oral
Written
Baranggay Agreement
Injuries
Accident
Intentional
Damage to Property
Other (Please specify):
________________________________
______
________________________________
______
2. _______ Barangay Conciliation
Required?
If yes, _______ Certificate to
File
Action;
_______ Compromise
(c). How did you compute the money owed you? (Do not include court
costs or fees.)
(Paano mo kinuwenta ang salaping utang sa iyo?) (Hindi kasama ang
bayad sa
pagpapatala sa hukuman.)
__________________________________________________________________________________
__________________
__________________________________________________________________________________
__________________
__________________________________________________________________________________
__________________
3. (a). Did you ask the defendant/s to pay you before you filed this
case?
(Siningil mo ba ang Hinahabla bago ka nagsampa ng kasong ito?)
Yes
(Oo)
No
(Hindi)
If no,
explain:_________________________________________________________________________
___________
(Kung hindi, ipaliwanag.)
(b). How did you ask the defendant/s?
(Paano mo siningil ang hinahabla?)
In person
(Sa kanya mismo)
In writing
specify)______________________
(Sa sulat)
paano.)
By phone
(Sa telepono)
Others, (please
(Iba pa, pakisulat kung
(c). When did you do this?

(Kailan mo ginawa ito?)
4. What is your proof that defendant/s owe/s you money?
(Ano ang iyong katibayan o pruweba na ang Hinahabla ay may utang na salapi
sa iyo?)
5. Did you attach your proof to this for?
(Iyo bang inilakip ang katibayan o pruweba sa Form na ito?)
Yes
(Oo)
No
(Hindi)
6. Was this claim referred to the barangay?
(Dumaan ba sa barangay ang paniningil na ito?)

Yes
(Oo)
No
Not Covered
(Hindi)
(Hindi sakop)
If yes, do you have a Certificate to File Action or a Compromise

Agreement executed before the barangay?
___________________________________________________________________________
(Kung oo, meron ka bang Patunay sa Pagsasampa ng Kaso o Kasunduan na
isinagawa sa barangay?)
6-a. In this court station, how many small claims cases have you
file within this
calendar year prior to this present case?
_________________________________________
(Sa court station na ito, pang-ilang kaso na small claim/s na itong
isinampa mo sa
loob ng kasalukuyang taon? _____________________________________ )
7. By the filing of this action, plaintiff hereby waives any amount in
excess of PHP100,000.00, excluding interests and costs.
(Sa pagsampa ng kasong ito, ang Naghahabla ay isinusuko ang anumang
halaga na higit sa PHP100,000.00, hindi kasama ang tubo at gastos sa
pagsampa ng kasong ito.)
PRAYER
(PAGSAMO)
WHEREFORE, plaintiff respectfully prays for judgment ordering
defendant to pay plaintiff the amount of PHP_______________________________,
with interest at the rate of _____% per annum/per month, from
__________________________________, until fully paid.
(DAHIL DITO, ang Naghahabla ay magalang na sumasamo na igawad ang
kapasiyahang utusan ang Hinahabla na magbayad sa Naghahabla ng halagang
PHP___________________________ pati ang tubo na ___________% bawat taon/buwan
simula _______________________________ hanggang ganap o lubos na mabayaran
ito.)
_______________________________________; _________________20___.
PLACE WHERE FILED
Date
(Lugar kung saan inihain)
(Petsa)
______________________________________
PLAINTIFF
(Naghahabla)
Republic of the Philippines]
Santa Cruz, Laguna
] s.s.
VERIFICATION AND CERTIFICATION OF

NON-FORUM SHOPPING
I, _________________________________, of legal age, ____________________

__________________________________, and a resident of
____________________________________________________ , after having been duly
sworn to in accordance with law, hereby, depose and say:
1. That I as the Plaintiff in the above-entitled case have caused this
Statement of Claim to be prepared; that I read and understood its
contents which are true and correct of my own personal knowledge
and/or based on authentic records;
2. That I have not commenced any action or proceeding involving the
same issue in the Supreme Court, the Court of Appeals or any other
tribunal or agency; 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.
IN WITNESS WHEREOF, I have hereunto set my hand this ______ day of
_____________, 2012
in Santa Cruz, Laguna.
_____________________________________
Affiant
SUBSCRIBED AND SWORN to before me this _______ day of
_________________________, 2012 by affiant with
_______________________________________ issued on ___________________ at
_____________________.
Doc. No. ________;
Page No. ________;
Book No. ________;
Series of 2012.

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A.M. No.

REPUBLIC OF THE PHILIPPINES

MUNICIPAL TRIAL COURT

Civil Case No.

(Town/City) _______BRGY._SAN JOSE, SANTA

Telephone No. ____________________________

NAME OF REPRESENTATIVE, if applicable _________LAARNI

(Town/City) ______BRGY. SAN JOSE, SANTA

Telephone No. ____________________________

(Lalawigan, king meron)

Telephone No. ____________________________

Telephone No. ____________________________

(*Tala: Kung kailangan ng karagdagang patlang, maaaring isulat sa likod ng Form

If no specific date, give the

ang tantiyang panahon)

(c). When did you do this?

6. Was this claim referred to the barangay?

(Dumaan ba sa barangay ang paniningil na ito?)

If yes, do you have a Certificate to File Action or a Compromise

VERIFICATION AND CERTIFICATION OF

I, _________________________________, of legal age, ____________________

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