STATEMENT OF CLAIM-PLAINTIFF

REPUBLIC OF THE PHILIPPINES

_______________________________
_______________________________
_______________________________

_________________________,
Plaintiff,
- versus -. Civil Case No. ___________
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

(Put a check on any of the following)

[ ] INDIVIDUAL [ ] CORPORATION [ ] PARTNERSHIP

[ ] COOPERATIVE [ ] SOLE PROPRIETORSHIP

HOME ADDRESS: (City) ____________________________________ _____________

ZIP CODE
(Province, if applicable) ______________________________________ _____________
ZIP CODE
Telephone No. __________________ Cellphone No. __________________

PLACE OF WORK: _______________________________________________________

NAME OF REPRESENTATIVE, if applicable: __________________________________

HOME ADDRESS: (City) ____________________________________ _____________
ZIP CODE
(Province, if applicable) ______________________________________ _____________
ZIP CODE
Telephone No. __________________ Cellphone No. __________________

PLACE OF WORK: _______________________________________________________

 ______________________ ____ ____ ______________
NAME OF DEFENDANT/S SEX AGE CIVIL STATUS

(Put a check on any of the following)

[ ] INDIVIDUAL [ ] CORPORATION [ ] PARTNERSHIP

[ ] COOPERATIVE [ ] SOLE PROPRIETORSHIP

HOME ADDRESS: (City) ____________________________________ _____________

ZIP CODE
(Province, if applicable) ______________________________________ _____________
ZIP CODE
Telephone No. __________________ Cellphone No. __________________

PLACE OF WORK: _______________________________________________________

NAME OF REPRESENTATIVE, if applicable: __________________________________

HOME ADDRESS: (City) ____________________________________ _____________
ZIP CODE
(Province, if applicable) ______________________________________ _____________
ZIP CODE
Telephone No. __________________ Cellphone No. __________________

PLACE OF WORK: _______________________________________________________

If more than one defendant, list next defendants here:

______________________ ____ ____ ______________

NAME OF PLAINTIFF/S SEX AGE CIVIL STATUS

(Put a check on any of the following)

[ ] INDIVIDUAL [ ] CORPORATION [ ] PARTNERSHIP

[ ] COOPERATIVE [ ] SOLE PROPRIETORSHIP

HOME ADDRESS: (City) ____________________________________ _____________

ZIP CODE
(Province, if applicable) ______________________________________ _____________
ZIP CODE
Telephone No. __________________ Cellphone No. __________________

PLACE OF WORK: _______________________________________________________

NAME OF REPRESENTATIVE, if applicable: __________________________________

HOME ADDRESS: (City) ____________________________________ _____________
ZIP CODE
(Province, if applicable) ______________________________________ _____________
ZIP CODE
Telephone No. __________________ Cellphone No. __________________

PLACE OF WORK: _______________________________________________________

2. Plaintiff claims the defendant

owes FOR OFFICIAL USE ONLY
₱ ________ (To be accomplished by the Clerk of
Court)
(a) Why does the defendant
owe plaintiff money? 1. Cause of action:
___________________ [ ] Check
___________________ [ ] Promissory Note
___________________ [ ] Contract
[ ] Oral [ ] Written
(b) When did this happen? [ ] Barangay Agreement
Date: ______________ [ ] Injuries
[ ] Accidental
If no specific date, give [ ] Intentional
the time period: [ ] Damage to property
[ ] Others (please specify)
(c) How did you compute _____________________
the money owed to you?
(Do not include court 2. ____ Barangay conciliation required
costs or fees) ________ If yes, ____ Certificate to File
___________________ Action
___________________ ____ Compromise
Agreement
3. (a) Did you ask the attached
defendant to pay you before ____ Barangay conciliation not
you filed this case? required
[ ] Yes [ ] No
If no, explain: _______ Please state the reason
___________________ _____________________
(b) How did you ask the
defendant?
[ ] In person[ ] By phone
[ ] In writing
[ ] Others (pls. specify)
___________________

(c) When did you do this? _______________________________________________

 4. What is the proof that defendant owes you money?
______________________________________________

5. Did you attach your proof to this form?

[ ] Yes [ ] No

6. Was this claim referred to the barangay?

[ ] Yes [ ] No [ ] Not covered

State reason: ______________________________________________

If yes, do you have a Certificate to File action or a Compromise Agreement

Executed before the barangay?_____________________________

7. BY THE FILING OF THIS ACTION, PLAINTIFF HEREBY WAIVESS ANY

AMOUNT IN EXCESS OF P100,000.00, EXCLUDING INTEREST AND COSTS.

PRAYER

WHEREFORE, plaintiff respectfully prays for judgment ordering defendant to pay the
amount of P _______________, with interest at the rate of_____% per annum/per month from
______________ until fully paid. ______________, _______, 20__.

PLACE WHERE FILED

_______________________
PLAINTIFF