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.