Republic of the Philippines

____________________________________
________________________
Branch ___

_______________________________,
Plaintiff,
__________________

Civil Case No.

-versus_____________________________

For:

_______________________________,
Defendant.
x---------------------------------------x
STATEMENT OF CLAIM
1. The personal circumstances of the parties are as
follows:
Name of Plaintiff/s

Sex

Age

_____________________________ _________ ______

__________
___
___
_____________________________ _________ ______
__________
___
___

Civil
Status
__________
____
__________
____

[ ] Individual
[ ] Corporation
[ ] Partnership
[ ] Cooperative
[ ] Sole Proprietorship
Name
of
Representative:
______________________________________________________
Address:
______________________________________________________
Zip
Code: _______
Name of Defendant/s

Sex

Age

_____________________________ _________ ______

__________
___
___
_____________________________ _________ ______
__________
___
___

Civil
Status
__________
____
__________
____

[ ] Individual
[ ] Corporation
[ ] Partnership
[ ] Cooperative
[ ] Sole Proprietorship
2. That plaintiff is suing defendant for:
CAUSE OF ACTION:
______ 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

AFFIDAVITS

______
______
______
______

How many: _______

Promissory Note / Undertaking

Contract / Agreement
Receipt
Others

4. The principal obligation of defendant/s amounting to

____________________________________________________
(Php ________________), Philippine currency, became due
and demandable on ____________________, Interest at the
rate of _________ % per annum/per month accrued on
the principal sum due from such date of default.
5. Despite repeated demands by plaintiff, the latest of
which was on _____________________, defendant has
failed to pay obligation.
6. ______ (a) This claim has been referred to the
appropriate barangay authority but no settlement was
reached between parties. A Certificate to File Action
was issued to the plaintiff, the original of which is
attached hereto.
______ (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
_____________________________________
(Php
_______________), Philippine currency, with interest at the
rate of _______ % per annum/per month, from
______________, until fully paid.
_______________________________,
______________________.

Philippines,

___________________________
Plaintif

VERIFICATION AND CERTIFICATION OF

NON-FORUM SHOPPING
I, ______________________________________, of legal age,
Filipino, single/married/widowed, and a resident of
______________________
______________________________________________________, after
having duly sworn in accordance with law, hereby depose
and state:
1. That I am the plaintiff of the above-entitled case and
have caused the preparation of the foregoing;
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 no commenced any action or proceeding
involving the same issue in the Supreme Court, the
Court of Appeals or and 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 and 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, 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 _________________________ at ________________________,
Philippines.

________________________________
Affiant
SUBSCRIBED AND SWORN to before me this in the place
and date above-mentioned.