HSAC Case Form No.

01

Republic of the Philippines

HUMAN SETTLEMENTS ADJUDICATION COMMISSION
Regional Adjudication Branch __________
___________ City

______________________
______________________
______________________,
Complainant/s,

- versus -
HSAC Case No. ____-________-______
______________________
______________________
______________________,
Respondent/s.

x----------------------------------------------------x

COMPLAINT

1. The complainant(s) is/are:

NAME SEX/AGE/NATIONALITY ADDRESS/EMAIL ADDRESS CONTACT NO.

(Note: If more space is needed, please use additional sheet, indicate “Continuation of Par. 1”, and countersign.)

2. The respondent(s) is/are:

NAME POSITION (IF APPLICABLE) ADDRESS/EMAIL ADDRESS

(Note: If more space is needed, please use additional sheet, indicate “Continuation of Par. 2”, and countersign.)
3. This complaint is for: (Please check as are applicable.)

[ ] Violation of Presidential Decree No. 957:

____ Selling of subdivision lots/condominium units without license to
sell (Sec. 5)
____ Mortgage of title without clearance (Sec. 18)
____ Failure to provide facilities advertised (Sec. 19 and 20)
____ Non-development (Sec. 20)
____ Incomplete Development (Sec. 20)
____ Unauthorized alteration of plan (Sec. 22)
____ Non-delivery of title (Sec. 25)
____ Collection of real estate tax prior to buyer's occupation (Sec. 26)
____ Unauthorized collection of dues by project owner/developer (Sec.
27)
____ Illegal use of open space (Sec. 31, as amended by PD 1216)
____ Others:
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________

[ ] Violation of RA 6552 (Maceda Law)

____ Cancellation of contract without factual basis
____ Cancellation of contract without complying with grace period or
notice requirements
____ Failure to refund cash surrender value
____ Others:
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________

[ ] Breach of specific contractual obligations, particularly the

obligation to:
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________

[ ] Other acts/violations of the respondent(s) complained of:

______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________

(Note: If more space is needed, please use additional sheet, indicate “Continuation of Par. 3”, and countersign.)

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4. The above violation(s) was/were committed as follows: (For each violation checked
or cited above, briefly and clearly narrate the facts, incidents or circumstances that
led to the filling of this complaint, stating the dates of occurrence, persons involved
and the specific acts done by the respondent(s).)

(1) Alleged violation: _______________________________________

Narration of facts/incidents/circumstances:
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________

(2) Alleged Violation: _______________________________________

Narration of facts/incidents/circumstances:
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________

(3) Alleged Violation: _______________________________________

Narration of facts/incidents/circumstances:
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________

(Note: If more space is needed, please use additional sheet, indicate “Continuation of Par. 4”, and countersign.)

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5. As evidence of the foregoing facts and circumstances, I/we are attaching the
following documents and affidavit as Annexes to this Complaint:

Purpose of Document
Annex Description of
(What fact or circumstance does the
Document
document prove or show?)
“A”

(Note: If more space is needed, please use additional sheet, indicate "Continuation of Par. 5", and countersign.)

6. Complainant(s) is/are seeking the following relief(s):

(1) ____________________________________________________
____________________________________________________
(2) ____________________________________________________
____________________________________________________
(3) ____________________________________________________
____________________________________________________
(4) ____________________________________________________
____________________________________________________
(5) ____________________________________________________
____________________________________________________
(Note: If more space is needed, please use additional sheet, indicate "Continuation of Par. 6", and countersign.)

7. Complainant(s) also seek(s) the payment of damages in his/her/their favor, and

have attached proof under Paragraph 5 above that he/she/they are entitled to said
damages:

_____ Actual/Compensatory damages in the amount of ₱______________

 Proof attached as Annex “___”
_____ Moral damages in the amount of ₱_______________
_____ Exemplary damages in the amount of ₱ _______________
_____ Attorney’s fees in the amount of ₱ _______________
 Proof attached as Annex “___”
_____ Cost of litigation in the amount of ₱_______________
 Proof attached as Annex “___”

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8. Complainant(s) also pray(s) that, pending the resolution of the case, the following
provisional remedy(ies) be issued in accordance with Part 3 of the HSAC Rules of
Procedure:

(1) Provisional remedy(ies) prayed for: _____________________________

Circumstances justifying the issuance of the provisional remedy(ies):
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________

As proof of these circumstances, I/we am/are attaching the following

documentary evidence as Annex(es) “___________”.

_____________________, Philippines, _____________.

(PLACE) (DATE)

(Note: If there is more than one complainant, each shall sign.)

Complainant(s) (Signature over printed name)

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 VERIFICATION AND CERTIFICATION AGAINST FORUM SHOPPING

I/We, (Name(s)) __________________________, of legal age, Filipino/

_________, and a resident of ____________________________________,
after having been duly sworn in accordance with law, hereby depose and state:

1. That I/we am/are the complainant(s) in the above-entitled case and have
caused this Complaint to be prepared;

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

3. That I/we have not commenced any action or proceeding involving the same
issue or subject matter in the Supreme Court, the Court of Appeals or any other
tribunal or agency; that to the best of my/our 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/we should learn thereafter that a similar action
or proceeding has been filed or is pending before these courts or tribunal or
agency, I/we undertake to report that fact to the Commission within five (5)
calendar days therefrom.

__________________________
Complainant(s)

REPUBLIC OF THE PHILIPPINES)

________________________ ) S.S.

SUBSCRIBED AND SWORN to before me, this ______ day of

________________________, with affiant(s) exhibiting to me his/her/their
________________________, issued at _______________ on
________________.

Doc. No. _____; Notary Public

Page No. _____;
Book No. _____;
Series of _____.

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