Republic of the Philippines

Third Judicial Region

Municipal Trial Court
Sta. Maria, Bulacan

PERSEVIRANDA CRUZ
MENDOZA, doing business
in the name and style of
CMCM FEEDS SUPPLY &
VETERINARY CENTER,
Plaintif,

-versus- SMALL CLAIMS CASE

NO.______
For: Collection of Sum of
Money

MS. FIDELA OBRA

Defendants.
x---------------------
- - -x

STATEMENT OF CLAIM
1. The personal circumstances of the parties are as follows:

CMCM FEEDS SUPPLY & VETERINARY CENTERS

NAME OF PLAINTIFF/S

(Put check on the following)

INDIVIDUAL CORPORATION PARTNERSHIP

COOPERATIVE SOLE
PROPRIETORSHIP

HOME ADDRESS: J.P. Rizal St., Poblacion, Sta. Maria, Bulacan

3022 ;

Zip Code
(Province, if applicable) Bulacan
3022 ;
Zip Code

Telephone No. N/A Cellphone No. 0915-394-6032

PLACE OF WORK: SAME

NAME OF REPRESENTATIVE: PERSEVIRANDA C. MENDOZA

HOME ADDRESS: (City) 67 Caypombo, Sta. Maria,

3013
Zip Code
( Province, if applicable) Bulacan
3013
Zip
Code

Telephone No. N/A Cellphone No.0939-930-9800

MS. FIDELA OBRA Female unknown

Single ;
NAME OF DEFENDANT/S SEX AGE CIVIL
STATUS

(Put check on the following)

INDIVIDUAL CORPORATION PARTNERSHIP

COOPERATIVE SOLE
PROPRIETORSHIP

HOME ADDRESS: (City) Kamandalaan, San Jose del Monte City 3024

Zip Code
(Province, if applicable) Bulacan
3024
Zip Code

Telephone No. N/A Cellphone No. 0939-930-9800

PLACE OF WORK: N/A

NAME OF REPRESENTATIVE, if applicable N/A

HOME ADDRESS: (City) N/A N/A

Zip Code
( Province, if applicable) N/A
N/A
Zip Code

Telephone No. N/A Cellphone No. N/A

PLACE OF WORK: N/A

Telephone No. N/A Cellphone No. N/A

FOR OFFICIAL USE ONLY

To be accomplished by the Branch Clerk of
Court
2. Plaintiff claims the defendant owes
Thirty Two Thousand One Hundred1. Cause of action
Thirty Pesos (P32,130.00) Check
Promissory Note
(a) Why does the defendant owe Contract
Plaintiff money? Oral Written

The defendant received agricultural Barangay Agreement

and veterinary products Injuries
Accidental Intentional
(If you need more space, please use Damage to Property
Back page), Other (Please specify):
___________________________)
(a) When did this happen? 2. Barangay conciliation required.
Date: August 21, 2014 If yes, __ Certificate to File Action
September 7, 2014 __Compromise Agreement attached

If no specific date, give the time Barangay conciliation not required.

Period: Please state the reason)
Date started: _____________________________________
Through:

(c) How did you compute the money owed to you? (Do not
include court costs or fees) The Sales Invoice issued by the
Plaintiff, signed by the Defendant.

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

Yes No

If no, explain:___________________________________________________________

(b) How did you ask the defendant?

In person By phone

In writing Others (please specify)

 (c) When did you do this? 18 January 201610 October 2014

4. What is your proof that defendant owes you money? The Sales
Invoice issued by the Plaintiff, signed by the Defendant.

5. Did you attach your proof to this form?

Yes No

6. Was this claim referred to the barangay?

Yes No Not Covered

State reason:
The parties live in
different municipalities

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

Agreement Executed before the Barangay? N/A

6-A- In this court station, how many small claims cases have
you filed within this calendar year prior to this present case? 1

7. BY THE FILING OF THIS ACTION, PLAINTIFF HEREBY WAIVES ANY

AMOUNT IN EXCESS OF P200, 000.00, EXCLUDING INTEREST AND
COSTS.

PRAYER

WHEREFORE, plaintiff respectfully prays for judgment ordering

defendant to pay the amount of THIRTY TWO THOUSAND ONE
HUNDRED THIRTY PESOS (P32,130.00) with interest at the
rate 24% per annum, from 18 January 2016 until fully paid.

Sta. Maria, Bulacan, ___ September 2016.

PERSEVIRANDA C. MENDOZA
PLAINTIFF
REPUBLIC OF THE PHILIPPINES }
City of Meycauayan } S.S.

AFFIDAVIT

I, PERSEVIRANDA C. MENDOZA, Filipino, of legal age, and with

residence at 67 Caypombo, Sta. Maria, Bulacan, on oath, hereby depose
and state that:

1. I am the Sole Proprietor of CMCM Feeds Supply & Veterinary

Center with office address at New Public Market, J.P. Rizal St., Poblacion, Sta.
Maria, Bulacan.

2. I caused the preparation and institution of a Small Claims case

against Ms. Fidela Obra (Fidela), entitled Perseviranda Cruz Mendoza,
doing business in the name and style of CMCM Feeds Supply &
Veterinary Center v. Ms. Fidela Obra, to be filed before the Municipal
Trial Court of Sta. Maria, Sta. Maria, Bulacan;

3. Based on existing records and my direct personal knowledge of

the factual circumstances relevant to this case, on 21 August 2014 and 7
September 2014, Fidela received agricultural and veterinary products from
CMCM amounting to Thirty Two Thousand One Hundred Thirty Pesos
(P32,130.00) which remains to be unpaid as of the filing hereof;

4. Oral and written demands notwithstanding, Fidela still refuses to

settle his arrears to the Plaintiff.

5. I am executing this Affidavit pursuant to Sec. 9 of the 2016

Revised Rules of Procedure for Small Claims Cases.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___

day of September 2016, here at the City of Meycauayan, Bulacan.

PERSEVIRANDA CRUZ MENDOZA

Affiant

SUBSCRIBED AND SWORN TO before me this ___ day of September

2016 here at the City of Meycauayan, Bulacan. As proof of identity, affiant
exhibited to me her _________________________.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2016.