16

FORM 1-SCC

A.M. No. 08-8-7-SC

REPUBLIC OF THE PHILIPPINES

METROPOLITAN TRIAL COURT
NATIONAL CAPITAL JUDICIAL REGION
QUEZON CITY,BRANCH_____
ABIVA PUBLISHING HOUSE INC.,
Rep.by. LOLITA L. BODIAO

Plaintiff,
vs.

Civil Case No. ________________

For:

__________________________
IMELDA OPERIOS LEARNING SCHOOL INC.
AND/OR IMELDA L. OPERIO-President,

Defendant.
x- - - - - - - - - - - - - - - - - - - - - - - - - - x

STATEMENT OF CLAIM
(HABLA NG PAGSINGIL)
1. The personal circumstances of the parties are as follows:
(Ang bawat panig ay ang mga sumusunod)
ABIVA PUBLISHING HOUSE INC., ______
______
____________
NAME OF PLAINTIFF/S
SEX
AGE
CIVIL
STATUS
(Pangalan ng Naghahabla)
(Kasarian)
(Edad)
(Katayuang Sibil)
(Put a check on any of the following)
(Pumili sa mga sumusunod at lagyan ng tsek)
INDIVIDUAL
(Tao/Indibidwal)
(Bakasan)

CORPORATION
(Korporasyon)

PARTNERSHIP

COOPERATIVE
PROPRIETORSHIP
(Kooperatiba)
ari)

SOLE
(Solong Pagmamay-

2016 Revised Rules of Procedure for Small Claims Cases

17
NATURE OF BUSINESS:
(Uri ng Negosyo)
BANKING
(Bangko)

LENDING
(Pagpapautang)

OTHERS/PLEASE INDICATE________________________
(Iba pang uri ng negosyo)
PLAINTIFFS HOME ADDRESS:
(Pahatirang Sulat sa Bahay ng Naghahabla)
(City) ___________________________________
________
(Lungsod)
Code

Zip

(Province, if applicable)_______________________
________
(Lalawigan, kung meron)
Telephone No. ______________
No._____________
(Telepono Blg.)

Zip Code

Cellphone
(Selpon Blg.)

PLACE OF WORK: ___________________________________________

(Lugar ng Pinagtatrabahuan)
Telephone No. ______________ Cellphone No._____________
(Telepono Blg.) (Selpon Blg.)
NAME OF PLAINTIFFS REPRESENTATIVE:

LOLITA L. BODIAO (with Special Power of Attorney and

Secretarys Certificate As ANNEX A to A-1)
if applicable (must be a non-lawyer)
(Pangalan ng Kinatawan:)
(kung meron) [dapat hindi abogado]
HOME ADDRESS: (City) ________________________
________
(Pahatirang Sulat sa Bahay) (Lungsod)

Zip Code

(Province, if applicable)_________________________
________
(Lalawigan, kung meron)

18

Zip Code

A.M. No. 08-8-7-SC

Telephone No. ______________

No._____________
(Telepono Blg.) (Selpon Blg.)

Cellphone
(Selpon Blg.)

PLACE OF WORK: No. 851 G. Araneta Avenue Quezon City

(Lugar ng Pinagtatrabahuan)
Telephone No. ______________
No._____________
(Telepono Blg.)

Cellphone
(Selpon Blg.)

IMELDA OPERIOS LEARNING SCHOOL INC.,

AND/OR IMELDA L. OPERIO-President

NAME OF DEFENDANT/S
STATUS
(Pangalan ng Hinahabla)
(Katayuang Sibil)
INDIVIDUAL
(Tao/Indibidwal)
(Bakasan)
COOPERATIVE
(Kooperatiba)

SEX

AGE

(Kasarian)

(Edad)

CORPORATION
(Korporasyon)

CIVIL

PARTNERSHIP

SOLE PROPRIETORSHIP
(Solong Pagmamay-ari)

DEFENDANTS HOME ADDRESS:

(Pahatirang Sulat sa Bahay ng Hinahabla)

(City) No. 6 De Gloria St. Area B. Talanay Batasan Hills

________
(Lungsod)
Zip
Code
(Province, if applicable) Quezon City
(Lalawigan, kung meron)
Telephone No. ______________
No._____________
(Telepono Blg.)

Zip Code
Cellphone

(Selpon Blg.)

PLACE OF WORK: ___________________________________________

(Lugar ng Pinagtatrabahuan)
Telephone No. ______________
No._____________
(Telepono Blg.)

Cellphone
(Selpon Blg.)

2016 Revised Rules of Procedure for Small Claims Cases

19
NAME OF DEFENDANTS REPRESENTATIVE:
__________________________________________
if applicable (must be a non-lawyer)
(Pangalan ng Kinatawan:)
(kung meron) [dapat hindi abogado]
HOME ADDRESS: (City) ________________________ ________
(Pahatirang Sulat sa Bahay) (Lungsod) Zip Code
(Province, if applicable)_______________________
________
(Lalawigan, kung meron)
Telephone No. ______________
No._____________
(Telepono Blg.)

Zip Code
Cellphone

(Selpon Blg.)

PLACE OF WORK: ___________________________________________

(Lugar ng Pinagtatrabahuan)
Telephone No. ______________
No._____________

Cellphone

(Telepono Blg.)

(Selpon Blg.)

If more than one (1) defendant, list next defendant here:

(Kung higit sa isa (1) ang Hinahabla, ilagay ang susunod na
hinahabla
rito:)
_______________________
______
______
_____________
NAME OF DEFENDANT/S SEX
AGE
CIVIL
STATUS
(Pangalan ng Hinahabla) (Kasarian) (Edad)
(Katayuang
Sibil)
INDIVIDUAL
PARTNERSHIP
(Tao/Indibidwal)
(Bakasan)

CORPORATION
(Korporasyon)

COOPERATIVE
PROPRIETORSHIP
(Kooperatiba)
ari)

SOLE
(Solong Pagmamay-

DEFENDANTS HOME ADDRESS:

(Pahatirang Sulat sa Bahay ng Hinahabla)
(City) ___________________________________
(Lungsod)

20

________
Zip Code

A.M. No. 08-8-7-SC

(Province, if applicable)_______________________
________
(Lalawigan, kung meron)
Zip Code
Telephone No. ______________
No._____________
(Telepono Blg.)

Cellphone
(Selpon Blg.)

PLACE OF WORK: ___________________________________________

(Lugar ng Pinagtatrabahuan)

Telephone No. ______________

No._____________
(Telepono Blg.)

Cellphone
(Selpon Blg.)

NAME OF DEFENDANTS REPRESENTATIVE:

_________________________________________
if applicable (must be a non-lawyer)
(Pangalan ng Kinatawan:)
(kung meron) [dapat hindi abogado]
HOME ADDRESS: (City) ________________________
________
(Pahatirang Sulat sa Bahay) (Lungsod)
Code
(Province, if applicable)_______________________
________
(Lalawigan, kung meron)
Telephone No. ______________
No._____________
(Telepono Blg.)

Zip

Zip Code
Cellphone

(Selpon Blg.)

PLACE OF WORK: ___________________________________________

(Lugar ng Pinagtatrabahuan)
Telephone No. ______________
No._____________
(Telepono Blg.)

Cellphone
(Selpon Blg.)

*Note: If you need more space, you can write at the back of this
Form.
(*Tala: Kung kailangan mo ng karagdagang patlang, maaari mong
isulat
sa likod ng Form na ito.)

2016 Revised Rules of Procedure for Small Claims Cases

21
2. Plaintiff claims the defendant owes him/her/it
P 155,868.42.
(Ang Hinahabla ay umutang sa Naghahabla ng halagang)
(a) Why does the defendant owe plaintiff money?

(Bakit ang Hinahabla ay nagkautang ng salapi sa

Naghahabla?)
Defendant have unpaid obligation for books
purchase on credit from the plaintif.
(If you need more space, please use the back page). (Kung
kailangan
mo ng karagdagang patlang, maaaring gamitin ang likod ng
pahinang ito.)
(b) When did this happen?
(Kailan ito nangyari?)
Date: It happened dated April 2012, July 2012
(Petsa)
If no specific date, give the time period:
(Kung walang tiyak na petsa, ibigay ang tantiyang panahon)
Date started: _______________________
(Petsa nagsimula)
Through: _______________________
(Hanggang)
(c) How did you compute the money owed to you? (Do not include
court costs or fees)
Based on the records and statement of accounts.
(Attached as Annex B

(Paano mo kinuwenta ang salaping inutang sa iyo?) [Hindi

kasama
ang bayad sa pagpapatala sa hukuman.]
3. (a) Did you ask the defendant to pay you before you filed this
case?
(Siningil mo ba ang Hinahabla bago ka nagsampa ng kasong
ito?)
Yes
(Oo)

No
(Hindi)

If no, explain:
__________________________________________________________________
_____
(Kung hindi, ipaliwanag)

22

A.M. No. 08-8-7-SC

(b) How did you ask the defendant?
Paano mo siningil ang Hinahabla?)
In person
(Sa kanya mismo)

By phone
(Sa telepono)

In writing Others (please specify) ______

(Sa sulat) (Iba pa) [pakisulat kung paano]
(c) When did you do this?
Oct 22 & 28, 2015, Nov. 4&5,2015 (attached as
Annex C toC-3
(Kailan mo ginawa ito?)
4. What is your proof that defendant owes you money?
1,Proposal Letter 2. Delivery Receipts 3. Service Reports
4.Collection Receipts attached as Annex D to D-6.

(Ano ang iyong katibayan o pruweba na ang Hinahabla ay may

utang na
salapi sa iyo?)
5. Did you attach your proof to this form?
(Iyo bang inilakip ang katibayan o pruweba sa Form na ito?)
Yes
(Oo)

No
(Hindi)

6. Was this claim referred to the barangay?

(Dumaan ba sa barangay ang paniningil na ito?)
Yes
(Oo)

No
(Hindi)

Not Covered
(Hindi sakop)

State reason:
Corporation not covered barangay concillation.
(Isulat ang dahilan)
If yes, do you have a Certificate to File Action or a Compromise
Agreement
executed before the barangay?
________________________________________
(Kung oo, meron ka bang Patunay sa Pagsampa ng Kaso o
Kasunduan
na isinagawa sa barangay?)
6-A. How many small claims cases have you filed within this
calendar
year prior to this present case, in this court station and
in the entire
country: None.

(Pang ilang kaso na itong isinampa mo sa loob ng

kasalakuyang
taon sa korte na ito at sa buong bansa?)

2016 Revised Rules of Procedure for Small Claims Cases

23
7. By the filing of this action, plaintiff hereby waives any amount
in excess
of P200,000.00, excluding interest and costs.
(Sa pagsampa ng kasong ito, ang Naghahabla ay isinusuko ang
anumang
halaga na higit sa P200,000.00, hindi kasama ang tubo at
gastos sa
pagsampa ng kasong ito.)
PRAYER
(PAGSAMO)
WHEREFORE, plaintiff respectfully prays for judgment
ordering defendant to pay the amount of P 81400.00, with
interest at the rate of
12% per annum/per month from the date of demand until fully
paid.
(DAHIL DITO, ang Naghahabla ay magalang na sumasamo na
igawad
ang kapasiyahang utusan ang Hinahabla na magbayad sa
Naghahabla
ng
halagang P___________________,
pati
ang
tubo
na
_____________% bawat taon/
buwan simula _________________________ hanggang ganap o lubos
na
mabayaran
ito.) __________________________________, ____________, 20___.

KRISTOFFER JOHN A. AVELINO

PLAINTIFF
(Naghahabla)
FOR OFFICIAL USE ONLY
(Para sa Opisyal na gamit lamang)
- To be accomplished by the Branch Clerk of
Court(Sasagutan ng Kawani ng Hukuman)

1. Cause of action
Check
Promissory Note
Contract
Oral Written
Barangay Agreement
Others (Please specify):
_________________________________.
2. _____ Barangay conciliation required.
If yes, _____ Certificate to File Action
_____ Compromise Agreement
attached.
_____ Barangay conciliation not required.
Please state the reason):
________________________________________.

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FORM 1-A-SCC

A.M. No. 08-8-7-SC

VERIFICATION AND CERTIFICATION AGAINST

NON-FORUM SHOPPING, SPLITTING A SINGLE CAUSE
OF ACTION AND MULTIPLICITY OF SUITS
I,KRISTOFFER JOHN A. AVELINO of legal age, Filipino
Citizen, and
(name)
(citizenship)
______________________________a resident of G/F Bldg. Teosijo
Subd. Tunasan.
(civil status)
(residence)
Muntinlupa City.
on oath, state:
1.
That I am the Attorney-in Fact in the above-entitled case
have
caused this complaint for Sum of Money to be prepared;
that
I read and understood its contents which are true and correct
of my own personal knowledge and/or based on true records;
2.

That I have not commenced any action or proceeding

involving the same issue or subject matter, and specifically
the same check/s in the Supreme Court, the Court of Appeals
or any other tribunal or agency, particularly before the Office
of the City Prosecutor of Muntinlupa City; 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.
3.
That the filing of this case is not in violation of the rule
against splitting
a single cause of action or multiplicity of suits.
4.
That I knowingly and voluntarily waive and forego the
institution of any
criminal complaint for Violation of Batas Pambansa Blg. 22
against the
defendant herein based on the same check/s subject matter
of this
Small Claims Complaint.
ARHC. CHARINA AMANDA B. JAVIER Filipino Citizen
(name)
(citizenship)
____________________________
St. Esguerra cor.
(civil status)

Unit 2 C&D Symphony Tower

(residence)

Timog Ave. Quezon City

2016 Revised Rules of Procedure for Small Claims Cases

25

IN WITNESS WHEREOF, I have hereunto set my hand this day of

______________, 20_____.

KRISTOFFER JOHN A.
AVELINO
Affiant
SUBSCRIBED AND SWORN to before me this ____________ day of
______________, 2016.
____________________
__
NOTARY PUBLIC