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
Document
the 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) “ ”.

Other reliefs and remedies just and equitable under the premises are likewise
prayed for.

, 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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