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FORM 1-SCC

REPUBLIC OF THE PHILIPPINES

First Judicial Region in Cities
Municipal Trial Court
Alaminos City, Pangasinan

SECURITY PILLARS CREDIT CORP.

Plaintiff,
Represented By: Arnulfo T. Bautista

Versus Small Claim Case No.

For: Collection of sum of money

SPS. FELIPE S. CAMBA and YOLANDA M. CAMBA

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)

SECURITY PILLARS CREDIT CORP. N/A N/A N/A

NAME OF PLAINTIF/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  CORPORATION ☐ PARTNERSHIP

(Tao/Indibiduwal) (Korporasyon) (Bakasan)

☐ COOPERATIVE ☐ SOLE PROPRIETORSHIP

(Kooperatiba) (Solong Pagmamay-ari
NATURE OF BUSINESS:
(Uri ng Negosyo)

☐ BANKING  LENDING
(Bangko) (Pagpapautang)

☐ OTHERS/PLEASE INDICATE N/A

(Iba pang uri ng negosyo)

PLAINTIFF’S HOME ADDRESS:

(Pahatirang Sulat sa Bahay ng Naghahabla)

(City) 2nd Floor Cuison Bldg. #4 San Jose Dr., Poblacion, 2404
Alaminos City
(Lungsod) Zip Code
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(Province, if applicable) Pangasinan

(Lalawigan kung meron) Zip Code
Telephone No. N/A Cellphone No. 09175014342
(Telepono Blg.) (Selpon Blg.)

PLACE OF WORK: N/A

(Lugar ng Pinagtatrabahuhan)
Telephone No. N/A Cellphone No. N/A
(Telepono Blg.) (Selpon Blg.)

NAME OF PLAINTIFF’S REPRESENTATIVE

MR. ARNULFO T. BAUTISTA
If applicable (must be a non-lawyer)
(Pangalang ng Kinatawan)
Kung meron (dapat hindi abogado)

HOME ADDRESS: (City) 2nd Floor Cuison Bldg. #4 San Jose 2404
Dr.,Poblacion, Alaminos City
(Pahatirang Sulat sa Bahay)(Lungsod) Zip Code

(Province, if applicable) Pangasinan

(Lalawigan, kung meron) Zip Code

PLACE OF WORK: 2nd Floor Cuison Bldg. #4 San Jose Dr.,

Poblacion, Alaminos City
(Lugar ng Pinagtatrabahuhan)

Telephone No. Cellphone No. 0955-821-4942

(Telepono Blg.) (Selpon Blg.)

SPS. FELIPE S. CAMBA and YOLANDA M. F 54 MARRIED

CAMBA
NAME OF DEFENDANT/S Sex Age Civil Status
(Pangalan ng Hinahabla) (Kasarian) (Edad) (Katayuang Sibil)

 INDIVIDUAL ☐ CORPORATION ☐ PARTNERSHIP

(Tao/Indibiduwal) (Korporasyon) (Bakasan)

☐ COOPERATIVE ☐ SOLE PROPRIETORSHIP

(Kooperatiba) (Solong Pagmamay-ari

DEFENDANT’S HOME ADDRESS:

(Pahatirang Sulat sa Bahay ng Naghahabla)

(City) BALANGOBONG ALAMINOS CITY PANGASINAN 2404

(Lungsod) Zip Code
PANGASINAN
(Province, if applicable)
(Lalawigan kung meron) Zip Code
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Telephone No. N/A Cellphone No. N/A

(Telepono Blg.) (Selpon Blg.)
PLACE OF WORK: N/A
(Lugar ng Pinagtatrabahuhan)

Telephone N/A Cellphone N/A

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

NAME OF DEFENDANT’S REPRESENTATIVE

N/A
If applicable (must be a non-lawyer)
(Pangalang ng Kinatawan)
Kung meron (dapat hindi abogado)
HOME ADDRESS: N/A N/A
(City)
(Pahatirang Sulat sa Bahay)(Lungsod) Zip Code

(Province, if applicable) N/A N/A

(Lalawigan, kung meron) Zip Code

Telephone No. N/A Cellphone No. N/A

(Telepono Blg.) (Selpon Blg.)
PLACE OF WORK: N/A
(Lugar ng PInagtatrabahuhan)

Telephone No. N/A Cellphone No. N/A

(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):
N/A N/A N/A

NAME OF DEFENDANT/S Sex Age Civil Status

(Pangalan ng Hinahabla) (Kasarian (Edad (Katayuang Sibil)
) )
☐ INDIVIDUAL ☐ CORPORATION ☐ PARTNERSHIP
(Tao/Indibiduwal) (Korporasyon) (Bakasan)

☐ COOPERATIVE ☐ SOLE PROPRIETORSHIP

(Kooperatiba) (Solong Pagmamay-ari

DEFENDANT’S HOME ADDRESS:

(Pahatirang Sulat sa Bahay ng Naghahabla)
(City N/A N/A
)(Lungsod) Zip Code

(Province, if applicable) N/A

(Lalawigan kung meron) Zip Code

Telephone No. N/A Cellphone No. N/A

(Telepono Blg.) (Selpon Blg.)
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PLACE OF WORK: N/A

(Lugar ng PInagtatrabahuhan)
Telephone N/A Cellphone No. N/A
(Telepono Blg.) (Selpon Blg.)

NAME OF DEFENDANT’S REPRESENTATIVE

N/A
If applicable (must be a non-lawyer)
(Pangalang ng Kinatawan)
Kung meron (dapat hindi abogado)
HOME ADDRESS: (City) N/A N/A
(Pahatirang Sulat sa Bahay)(Lungsod) Zip Code

(Province, if applicable) N/A N/A

(Lalawigan, kung meron) Zip Code

Telephone No. N/A Cellphone No. N/A

(Telepono Blg.) (Selpon Blg.)
PLACE OF WORK: N/A
(Lugar ng PInagtatrabahuhan)
Telephone No. N/A Cellphone No. N/A
(Telepono Blg.) (Selpon Blg.)

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

2. Plaintif claims the defendant owes him/her/it

Ph 60,000.00
(Ang Hinahabla ay umutang sa Naghahabla ng halagang)
a. Why does the defendant owe plaintif money?
(Bakit ang Hinahabla ay nagkautang ng salapi sa Naghahabla?)
TO BE USED AS ADDITIONAL WORKING CAPITAL FOR THEIR BUSINESS.
(KARAGDAGANG PUHUNAN SA KANILANG NEGOSYO.)

(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: JULY 16, 2019
(Petsa)
If no specific date, give the time period:
(Kung walang tiyak na petsa, ibigay ang tantiyang panahon)
Date
(Petsa nagsimula)
Through
(Hanggang)
c. How did you compute the money owed to you? (Do not include court costs or fees)
DEPENDANTS OBLIGATION WAS COMPUTED BASED ON PRINCIPAL, AMOUNT OF
LOAN PLUS INTEREST & PENALTY CHARGES AS STIPULATED IN THE
PROMISORRY NOTE. (ANG KABUUANG UTANG AY KINUWENTA KASAMA ANG
INTEREST AT PENALTY CHARGED NA NAKASAAD SA PROMISORRY NOTE.)
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(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 moba ang hinahabla bago ka nagsampa ng kasong ito?)

 Yes ☐ No
(oo) (Hindi)

If no, explain:
N/A
(Kung hindi, ipaliwanag)

(b). How did you ask the defendant?

(Paano mo siningil ang Hinahabla?)

☐ In person ☐ By phone
(Sa kanya (Sa telepono)
mismo)
 In writing ☐ Others (please specify) N/A
(Sa sulat) (Iba pa. Pakisulat kung paano)
(c). When did you do this?
JANUARY 19, 2021; JANUARY 27, 2021
(Kailan mo ito ginawa?)
4. What is your proof that defendant owes you money?
SECRETARY’S CERTIFICATE, STATEMENT OF ACCOUNT, PROMISORRY NOTE, DEMAND
LETTER
(Ano ang 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 anng katibayan o pruweba sa form na ito?)

☐ Yes  No
(oo) (Hindi)
6. Was this claim referred to the barangay?
(Dumaan basa barangay ang paniningil na ito?)

☐ Yes  No  Not Covered

(oo) (Hindi) (Hindi Sakop)
State reason:
N/A
(Isulat ang dahilan)
If yes, do you have a Certificate to File Action or a Compromise Agreement
executed
Before the barangay? N/A

(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
?(Pang-ilang kaso na itong isinampa mo sa loob ng kasalukuyang taon sa
korte na ito at sa buong bansa?)
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7. By the filing of this action, plaintiff hereby waives any amount in excess of
(Php300,000.00, excluding interests and costs.
(Sa pagsampa ng kasong ito, ang Naghahabla ay isinusuko ang anumang halaga na
higit sa Php 300,000.00, 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 Php 87,573.64 , with interest at the rate of
3.00 % per annum/per month from NOV.14, 2019 until fully paid.
(Dahil dito, ang naghahabla ay magalang na sumasamo na igawad ang
kapasiyahang utusan ang Hinahabla na magbayad sa Naghahabla ng halagang
Ph 87,573.64 , pati ang tubo na 3 33% bawat taon/ buwan simula
4 mabayaran ito.)
NOV. 14 2019 hanggang ganap o lubos na
AT ALAMINOS CITY PANGASINAN, APRIL 6, 2021

MR. ARNULFO T. BAUTISTA

PLAINTIFF
(Naghahabla)

FOR OFFICIAL USE ONLY (Para sa Opisyal na gamit lamang)

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 attached
Compromise Agreement attached
Barangay conciliation not required

(Please state the reason):

FORM 1-A-SCC
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VERIFICATION AND CERTIFICATION AGAINST NON-FORUM SHOPPING,
SPLITTING A SINGLE CAUSE OF ACTION AND MULTIPLICITY OF SUITS

I, Arnulfo T. Bautista of legal age, Filipino

(name) (citizenship)

Married , and a resident of 2nd Floor Cuison Bldg., #4 San Jose Dr.,
Poblacion Alaminos City
(civil status) (residence)

on oath, state:

1. That I am the Authorized Representative In the above-entitled case have caused this
Statement of Claims 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

; 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.

IN WITNESS WHEREOF, I have hereto set my hand Day

this
of , 20 ,

Mr. Arnulfo T. Bautista

Affiant

SUBSCRIBED AND SWORN to before me this Day

of , 20 ,

NOTARY PUBLIC
Doc. No. ________
Page No. ________
Book No.________
Series of 2021
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PLACE OF WORK: N/A

(Lugar ng Pinagtatrabahuhan)

Telephone N/A Cellphone N/A

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

NAME OF DEFENDANT’S REPRESENTATIVE

N/A
If applicable (must be a non-lawyer)
(Pangalang ng Kinatawan)
Kung meron (dapat hindi abogado)
HOME ADDRESS: N/A N/A
(City)
(Pahatirang Sulat sa Bahay)(Lungsod) Zip Code

(Province, if applicable) N/A N/A

(Lalawigan, kung meron) Zip Code

Telephone No. Cellphone No. N/A

(Telepono Blg.) (Selpon Blg.)
PLACE OF WORK: N/A
(Lugar ng PInagtatrabahuhan)

Telephone No. N/A Cellphone No. N/A

(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):
MS. GRACE S. DE VERA F 47 SINGLE

NAME OF DEFENDANT/S Sex Age Civil Status

(Pangalan ng Hinahabla) (Kasarian (Edad (Katayuang Sibil)
) )
 INDIVIDUAL ☐ CORPORATION ☐ PARTNERSHIP
(Tao/Indibiduwal) (Korporasyon) (Bakasan)

☐ COOPERATIVE ☐ SOLE PROPRIETORSHIP

(Kooperatiba) (Solong Pagmamay-ari

DEFENDANT’S HOME ADDRESS:

(Pahatirang Sulat sa Bahay ng Naghahabla)
(City TANAYTAY ALAMINOS CITY, 2404
)(Lungsod) Zip Code

(Province, if applicable) PANGASINAN N/A

(Lalawigan kung meron) Zip Code

Telephone No. N/A Cellphone No. N/A

(Telepono Blg.) (Selpon Blg.)
PLACE OF WORK: N/A
(Lugar ng PInagtatrabahuhan)