P

A
G
E


1



O
F


5

A.M. No. 08-8-7-SC
FORM 1-SCC


REPUBLIC OF THE PHILIPPINES
FOURTH JUDICIAL REGION
MUNICIPAL TRIAL COURT IN CITIES (MTCC)
DASMARIAS CITY, CAVITE

CESAR A. DELA VEGA,
Plaintiff,
vs. Civil Case No. ____________________________
FELIPE V. CATALAN, For: COLLECTION OF SUM OF MONEY
Defendant/s. INTERESTS and DAMAGES
x- - - - - - - - - - - - - - - - - - - - - - - -x


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)

CESAR A. DELA VEGA MALE 58 years MARRIED .
NAME OF PLAINTIFF/S SEX AGE CIVIL STATUS
(Pangalan ng Naghahabla) (Kasarian) (Edad) (Katayuang Sibil)

INDIVIDUAL CORPORATION PARTNERSHIP
(Tao/Indibidwal) (Korporasyon) (Bakasan)

COOPERATIVE SOLE PROPRIETORSHIP
(Kooperatiba) (Solong Pagmamay-ari)

HOME ADDRESS: ____BLK 34 LOT 39 KRYPTON STREET, GOLDEN CITY DASMA 4____
____PHASE 10, SALAWAG, DASMARIAS CITY, CAVITE_______________
(Pahatirang Sulat) (Bayan/Lungsod) _____________
(Zip Code)
(Province, if applicable) __________________CAVITE__________________ ______________
(Lalawigan, king meron) (Zip Code)

Telephone No. ____________________________ Cellphone No. __0927-7259776________
(Telepono Blg.) (Selpon Blg.)

PLACE OF WORK _________________________PASAY CITY________________________________
(Lugar ng Pinagtatrabahuhan)

NAME OF REPRESENTATIVE, if applicable ____________________N/A______________________
(Pangalan ng Kinatawan, kung meron)

HOME ADDRESS: (Town/City) ____________________N/A_____________________ _____________
(Pahatirang Sulat) (Bayan/Lungsod) (Zip Code)

(Province, if applicable) _______________________N/A____________________ ______________
(Lalawigan, kung meron) (Zip Code)

P
A
G
E


2



O
F


5

Telephone No. ____________________________ Cellphone No. ___________N/A____________
(Telepono Blg.) (Selpon Blg.)

FELIPE V. CATALAN . MALE 38 y.o. ___MARRIED__
NAME OF DEFENDANT/S SEX AGE CIVIL STATUS
(Pangalan ng Hinahabla) (Kasarian) (Edad) (Katayuang Sibil)

INDIVIDUAL CORPORATION PARTNERSHIP
(Tao/Indibidwal) (Korporasyon) (Bakasan)

COOPERATIVE SOLE PROPRIETORSHIP
(Kooperatiba) (Solong Pagmamay-ari)

HOME ADDRESS: ____BLK 25 LOT 14GERMANY ST., SAN MARINO, SALAWAG__________
____SALAWAG, DAMARIAS CITY, CAVITE______________________________
_____________
(Pahatirang Sulat) (Bayan/Lungsod) (Zip Code)

(Province, if applicable) __________________CAVITE_____________________ ______________
(Lalawigan, king meron) (Zip Code)

Telephone No. ____________________________ Cellphone No. _____________________________
(Telepono Blg.) (Selpon Blg.)

PLACE OF WORK __________________________________________________________________________________
(Lugar ng Pinagtatrabahuhan)

NAME OF REPRESENTATIVE, if applicable ______________________ N/A_______________________
(Pangalan ng Kinatawan, kung meron)

HOME ADDRESS: (Town/City) ____________________ N/A_____________________ _____________
(Pahatirang Sulat) (Bayan/Lungsod) (Zip Code)

(Province, if applicable) _______________________ N/A_____________________ ______________
(Lalawigan, king meron) (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:)

____________ N/A______________ ______ _____ _________________
NAME OF DEFENDANT/S SEX AGE CIVIL STATUS
(Pangalan ng Hinahabla) (Kasarian) (Edad) (Katayuang Sibil)

INDIVIDUAL CORPORATION PARTNERSHIP
(Tao/Indibidwal) (Korporasyon) (Bakasan)

COOPERATIVE SOLE PROPRIETORSHIP
(Kooperatiba) (Solong Pagmamay-ari)

HOME ADDRESS: (Town/City) _______________________ N/A___________________ _____________
(Pahatirang Sulat) (Bayan/Lungsod) (Zip Code)

(Province, if applicable) ______________________ N/A_____________________ ______________
(Lalawigan, king meron) (Zip Code)

Telephone No. ____________________________ Cellphone No. _____________________________
(Telepono Blg.) (Selpon Blg.)

P
A
G
E


3



O
F


5

PLACE OF WORK ____________________________________ N/A________________________________________
(Lugar ng Pinagtatrabahuhan)

NAME OF REPRESENTATIVE, if applicable ___________________ N/A__________________________
(Pangalan ng Kinatawan, kung meron)

HOME ADDRESS: (Town/City) _____________________ N/A_____________________ _____________
(Pahatirang Sulat) (Bayan/Lungsod) (Zip Code)

(Province, if applicable) _________________________________________________ ______________
(Lalawigan, king meron) (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 __________45,000.00______________.
(Ang hinahabla ay umutang sa
Naghahabla ng halagang
PHP___________45,000.00______________.)

(a). Why does the defendant/s owe
plaintiff/s money?
(Bakit ang Hinahabla ay nagkautang
ng salapi sa Naghahabla?)
_____Defendant borrowed money_______
_____due to personal reasons.____________
_______________________________________________
_______________________________________________
_______________________________________________


(b). When did this happen?
(Kailan ito nangyari?)
Date: __________OCT. 19, 2011________
(Petsa)

If no specific date, give the time
period:
(Kung walang tiyak na petsa, ibigay
ang tantiyang panahon)
Date started: ___________________________
(Petsa ng nagsimula)
Through: _______________________________
(Hanggang)































(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.)

______PRINCIPAL AMOUNT (PHP45,000.00) PLUS INTEREST AT 1% PER MONTH___
______PLUS DAMAGES (PHP25,000.00)______________________________________________________
____________________________________________________________________________________________________

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
Agreement attached.

_______ Barangay Conciliation Not
Required.
(Please state reason)
_______________________________
_______________________________

P
A
G
E


4



O
F


5


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 No
(Oo) (Hindi)

If no, explain:____________________________________________________________________________________
(Kung hindi, ipaliwanag.)

(b). How did you ask the defendant/s?
(Paano mo siningil ang hinahabla?)

In person By phone
(Sa kanya mismo) (Sa telepono)

In writing Others, (please specify)_BARANGGAYAN_
(Sa sulat) (Iba pa, pakisulat kung paano.)

(c). When did you do this? __DEC. 2011 TO FEB. 2012___
(Kailan mo ginawa ito?)

4. What is your proof that defendant/s owe/s you money? ___KASUNDUAN SA UTANG____
AND KASUNDUAN SA BARANGGAY____________________________________________________________
(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 No
(Oo) (Hindi)

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

Yes No Not Covered
(Oo) (Hindi) (Hindi sakop)

If yes, do you have a Certificate to File Action or a Compromise Agreement executed
before the barangay? ________YES (CERTIFICATE TO FILE ACTION)__________________________
(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? ____________ONLY THIS ONE___________
(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.)






P
A
G
E


5



O
F


5



PRAYER
(PAGSAMO)

WHEREFORE, plaintiff respectfully prays for judgment ordering defendant to pay
plaintiff the amount of PHP____45,000.00___, with interest at the rate of __12_% per
annum/per month, from _________DEC. 2011___________, until fully paid. Plus Damages
(PHP25,000.00).
(DAHIL DITO, ang Naghahabla ay magalang na sumasamo na igawad ang kapasiyahang
utusan ang Hinahabla na magbayad sa Naghahabla ng halagang PHP______45,000.00_____ pati ang
tubo na ___2____% bawat taon/buwan simula _______DEC. 2011____________ hanggang ganap o lubos
na mabayaran ito Pati damages (PHP25,000.00.)


__DASMARIAS CITY, CAVITE__; _________________2012.
PLACE WHERE FILED Date
(Lugar kung saan inihain) (Petsa)

____CESAR A. DELA VEGA__
PLAINTIFF
(Naghahabla)

Republic of the Philippines]
Dasmarias City, Cavite ] s.s.

VERIFICATION AND CERTIFICATION OF
NON-FORUM SHOPPING

I, _ CESAR A. DELA VEGA_, of legal age, _FILIPINO__ ______MARRIED_______________, and a
resident of _____BLK 34 LOT 39 KRYPTON STREET, GOLDEN CITY DASMA 4, PHASE 10,
SALAWAG, DASMARIAS CITY, CAVITE , 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 Dasmarias City, Cavite.


____CESAR A. DELA VEGA___
Affiant

SUBSCRIBED AND SWORN to before me this _______ day of _________________________, 2012 by
affiant with _I.D.__________________________________ issued on ___________________ at _____________________.

Doc. No. ________;
Page No. ________;
Book No. ________;
Series of 2012.