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.