FORM 1-SCC

Republic of the Philippines

____________ Judicial Region

________________ TRIAL COURT

Branch _____, _____________, _____________

STATEMENT OF CLAIM

(HABLA NG PAGSINGIL)

1. The personal circumstances of the parties are as follows: (Ang bawat panig ay ang mga sumusunod)

(Put a check on any of the following) (Pumili sa mga sumusunod at lagyan ng tsek)

NATURE OF BUSINESS: (Uri ng Negosyo)

PLAINTIFF’S HOME ADDRESS:

(Pahatirang Sulat sa Bahay ng Naghahabla)

(City) (Lungsod) ___________________________________ Zip Code ________

(Province, if applicable) (Lalawigan, kung meron) _______________________ Zip Code ________

Telephone No. (Telepono Blg.) ______________ Cellphone No. (Selpon Blg.) _____________

PLACE OF WORK: ___________________________________________

(Lugar ng Pinagtatrabahuan)

Telephone No. (Telepono Blg.) ______________ Cellphone No. (Selpon Blg.) _____________

NAME OF PLAINTIFF’S REPRESENTATIVE: (Pangalan ng Kinatawan:)

________________________________________________________

if applicable (must be a non-lawyer) (kung meron) [dapat hindi abogado]

HOME ADDRESS:

(Pahatirang Sulat sa Bahay ng Naghahabla)

(City) (Lungsod) ___________________________________ Zip Code ________

(Province, if applicable) (Lalawigan, kung meron) _______________________ Zip Code ________

Telephone No. (Telepono Blg.) ______________ Cellphone No. (Selpon Blg.) _____________

PLACE OF WORK: ___________________________________________

(Lugar ng Pinagtatrabahuan)

Telephone No. (Telepono Blg.) ______________ Cellphone No. (Selpon Blg.) _____________

DEFENDANT'S HOME ADDRESS:

(Pahatirang Sulat sa Bahay ng Hinahabla)

(City) (Lungsod) ___________________________________ Zip Code ________

(Province, if applicable) (Lalawigan, kung meron) _______________________ Zip Code ________

Telephone No. (Telepono Blg.) ______________ Cellphone No. (Selpon Blg.) _____________

PLACE OF WORK: ___________________________________________

(Lugar ng Pinagtatrabahuan)

Telephone No. (Telepono Blg.) ______________ Cellphone No. (Selpon Blg.) _____________

NAME OF DEFENDANT'S REPRESENTATIVE: (Pangalan ng Kinatawan:)

________________________________________________________

if applicable (must be a non-lawyer) (kung meron) [dapat hindi abogado]

HOME ADDRESS:

(Pahatirang Sulat sa Bahay ng Naghahabla)

(City) (Lungsod) ___________________________________ Zip Code ________

(Province, if applicable) (Lalawigan, kung meron) _______________________ Zip Code ________

Telephone No. (Telepono Blg.) ______________ Cellphone No. (Selpon Blg.) _____________

PLACE OF WORK: ___________________________________________

(Lugar ng Pinagtatrabahuan)

Telephone No. (Telepono Blg.) ______________ Cellphone No. (Selpon Blg.) _____________

If more than one (1) defendant, list next defendant here:

(Kung higit sa isa (1) ang Hinahabla, ilagay ang susunod na hinahabla rito:)

DEFENDANT'S HOME ADDRESS:

(Pahatirang Sulat sa Bahay ng Hinahabla)

(City) (Lungsod) ___________________________________ Zip Code ________

(Province, if applicable) (Lalawigan, kung meron) _______________________ Zip Code ________

Telephone No. (Telepono Blg.) ______________ Cellphone No. (Selpon Blg.) _____________

PLACE OF WORK: ___________________________________________

(Lugar ng Pinagtatrabahuan)

Telephone No. (Telepono Blg.) ______________ Cellphone No. (Selpon Blg.) _____________

NAME OF DEFENDANT'S REPRESENTATIVE: (Pangalan ng Kinatawan:)

________________________________________________________

if applicable (must be a non-lawyer) (kung meron) [dapat hindi abogado]

HOME ADDRESS:

(Pahatirang Sulat sa Bahay ng Naghahabla)

(City) (Lungsod) ___________________________________ Zip Code ________

(Province, if applicable) (Lalawigan, kung meron) _______________________ Zip Code ________

Telephone No. (Telepono Blg.) ______________ Cellphone No. (Selpon Blg.) _____________

PLACE OF WORK: ___________________________________________

(Lugar ng Pinagtatrabahuan)

Telephone No. (Telepono Blg.) ______________ Cellphone No. (Selpon Blg.) _____________

*Note: If you need more space, you can write at the back of this Form.

(*Tala: Kung kailangan mo ng karagdagang patlang, maaari mong isulat sa likod ng Form na ito.)

2. Plaintiff claims the defendant owes him/her/it P________________________.

(Ang Hinahabla ay umutang sa Naghahabla ng halagang)

(a) Why does the defendant owe plaintiff money?

(Bakit ang Hinahabla ay nagkautang ng salapi sa Naghahabla?)

_______________________________________________________________________________________________________.

(If you need more space, please use the back page).

(Kung kailangan mo ng karagdagang patlang, maaaring gamitin ang likod ng pahinang ito.)

(b) When did this happen? (Kailan ito nangyari?)

Date (Petsa) : _______________________

If no specific date, give the time period: (Kung walang tiyak na petsa, ibigay ang tantiyang panahon)

Date started (Petsa nagsimula): _______________________ Through (Hanggang): _______________________

(c) How did you compute the money owed to you? (Do not include court costs or fees)

(Paano mo kinuwenta ang salaping inutang sa iyo?) [Hindi kasama ang bayad sa pagpapatala sa hukuman.]

______________________________________________________________________________________________________.

3. (a) Did you ask the defendant to pay you before you filed this case?

(Siningil mo ba ang Hinahabla bago ka nagsampa ng kasong ito?)

If no, explain: ________________________________________________

(Kung hindi, ipaliwanag)

(b) How did you ask the defendant? (Paano mo siningil ang Hinahabla?)

(c) When did you do this? _________________________________________

(Kailan mo ginawa ito?)

4. What is your proof that defendant owes 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 form? (Iyo bang inilakip ang katibayan o pruweba sa Form na ito?)

6. Was this claim referred to the barangay? (Dumaan ba sa barangay ang paniningil na ito?)

State reason: _________________________________________________

(Isulat ang dahilan)

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 Pagsampa ng Kaso o Kasunduan na isinagawa sa barangay?)

______________________________

6-A. How many small claims cases have you filed within this calendar year prior to this present case, in this court station and in the entire country: _____

(Pang ilang kaso na itong isinampa mo sa loob ng kasalakuyang taon sa korte na ito at sa buong bansa?)

7. By the filing of this action, plaintiff hereby waives any amount in excess of P200,000.00, excluding interest and costs.

(Sa pagsampa ng kasong ito, ang Naghahabla ay isinusuko ang anumang halaga na higit sa P200,000.00, hindi kasama ang tubo at gastos sa pagsampa ng kasong ito.)

P R A Y E R

(PAGSAMO)

WHEREFORE, plaintiff respectfully prays for judgment ordering defen-dant to pay the amount of P ____________, 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 P_____________, pati ang tubo na ______% bawat taon/ buwan simula _______________ hanggang ganap o lubos na mabayaran ito.)

__________________________________, ____________, 20___.