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FORM 1-SCC

REPUBLIC OF THE PHILIPPINES


Municipal Circuit Trial Court
City of Malaybalay,
Province of Bukidnon

_____________________
Plaintiff, Civil Case No. ________________

Vs.
For: Collection of Sum of Money
_____________________
Defendants.
x- - - - - - - - - - - - - - - - - - - - - -x

STATEMENT OF CLAIM

Plaintiff respectfully alleges the:

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

__________________
NAME OF PLAINTIFF

___INDIVIDUAL__X__CORPORATION__ PARTNERSHIP__ SOLE PROPRIETORSHIP

OFFICE ADDRESS:
______________________________

NAME OF REPRESENTATIVE:
_______________________

ADDRESS:
____________________________

NAME OF DEFENDANT SEX AGE CIVIL STATUS

__________________ __________ _____ ____________


__X__INDIVIDUAL__ CORPORATION__ PARTNERSHIP__ SOLE PROPRIETORSHIP

HOME ADDRESS:
___________________________________


2. Plaintiff issuing defendant for:
CAUSE OF ACTION
__X_ Collection of Sum of Money
_____ Damages
_____ Civil aspect of Criminal Case
_____ Enforcement of Barangay Agreement

3. Plaintiffs cause of action arose from and is evidenced by:
ACTIONABLE DOCUMENT/S AFFIDAVIT/S
__X__ Promissory Note/Undertaking (Annex A & A-1) How many: _____
_____ Contract/Agreement
_____ Receipt
__X__ Others:
1. Listing of payment made as of _________2014 of _____________ showing that
his last payment was made last ________ and she has already defaulted
payments for ____ () months ( Annex ); and

2. Statement of Account as of April 30, 2014 of __________ (Client No.
01A002076) for Micro- DSK Loan with total amount due of P 21, 579.29 (Annex
)

3. Demand Letter dated ____________ ( Annex )

4. The principal obligation of defendants amounting to TEN THOUSAND NINE HUNDRED
TWENTY FOUR PESOS and FOUR CENTS ( P 10, 924.04) which became due and demandable
on September 6, 2013. In the conformity with the agreement of parties in the Promissory
Note, additional amount accrued as interest balance, penalty charges, service charge and
attorneys fee thus making the total monetary obligation of defendant to
_____________(P_______) subject to final computation upon payment of defendant.

5. Despite repeated demands by plaintiff, the latest of which was on________, defendant has
failed to pay the obligation.

6. __X__(a) This claim has been referred to the appropriate barangay authorities but no
settlement was reached between the parties. A Certificate to File Action was issued to the
plaintiff, the original of which is attached hereto as Annex .

__ __(b) The parties are not covered by the barangay mandatory conciliation process under
the Local Government Code of the Philippines.

PRAYER

WHEREFORE, plaintiff respectfully prays for judgment to be rendered ordering defendant to pay
plaintiff the amount of __________ PESOS (P___________).

Malaybalay City, Bukidnon, this __________ day of _________.






______________________
PLAINTIFF

Represented by:
___________________

Branch Manger
D ASIAN HILLS BANK, INC.
Valencia City Branch
FORM 1-A-SCC


VERIFICATION AND CERTIFICATION OF
NON-FORUM SHOPPING


I, __________________ , of legal age, Filipino, married and a resident of
____________________________, after having been duly sworn to in accordance with law,
hereby, depose and say:

1. That, I am the representative of the plaintiff in the above-entitled
case and have caused this Statement of Claim to be prepared;

2. That I read and understood its contents which are true and correct
of my own personal knowledge and/or based on authentic records;

3. 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;

4. 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 ______ 2014.

_______________________________

Affiant
Tax Identificatin No.
Issued by Bureau Of Internal
Revenue

SUBSCRIBED AND SWORN to before me this _____ day of____________ 2014.

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