statement of small claim sample form

 FORM 1-SCC
 
 
REPUBLIC OF THE PHILIPPINES

 
 
                                                          ,
Plaintiff,
 
For:                                                     
                                                          ,
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)
 
 
Telephone No.                                 Cellphone No.                              
(Telepono Blg.)                                    (Selpon Blg.) (Selpon Blg.)
 
PLACE OF WORK:                                                                                                  
(Lugar ng Pinagtatrabahuan)
 
Telephone No.                                 Cellphone No.                              
(Telepono Blg.)                                    (Selpon Blg.)
 
                                                 _
                             
NAME OF DEFENDANT/S              SEX               AGE            CIVIL STATUS
(Pangalan ng Hinahabla)    (Kasarian)   (Edad)   (Katayuang Sibil)
  INDIVIDUAL         CORPORATION         PARTNERSHIP
(Tao/Indibidwal)                 (Korporasyon)                    (Bakasan)COOPERATIVE                 SOLE PROPRIETORSHIP
(Kooperatiba)                          (Solong Pagmamay-ari)
 
DEFENDANT’S HOME ADDRESS:
(Pahatirang Sulat sa Bahay ng Hinahabla)
 
(City)                                                                                                      
(Lungsod)                                                                                    Zip Code
 
(Province, if applicable)                                                                        
(Lalawigan, kung meron)                                                         Zip Code
 
Telephone No.                                 Cellphone No.                              
(Telepono Blg.)                                    (Selpon Blg.)
 
PLACE OF WORK:                                                                                                  
(Lugar ng Pinagtatrabahuan)
 
Telephone No.                                 Cellphone No.                              
(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:)
 
 
 
 
PLACE OF WORK:                                                                                                  
(Lugar ng Pinagtatrabahuan)
 
Telephone No.                                 Cellphone No.                              
(Telepono Blg.)                                   (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.)
2.        Plaintiff claims the defendant owes him/her/it P                .
(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?)

                                                                                                                 .   (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:                                                     (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)
                                                                                                                 . (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?)

If no, explain:

(Kung hindi, ipaliwanag)
(b)       How did you ask the defendant?Paano mo siningil ang Hinahabla?)
 
 
(c)       When did you do this?

(Kailan mo ginawa ito?)
 
4.        What is your proof that defendant owes you money?

(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?)
6.        Was this claim referred to the barangay?

(Dumaan ba sa barangay ang paniningil na ito?)
State reason:

(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:            
(Pang ilang kaso na itong isinampa mo sa loob ng kasalakuyang taon sa korte na ito at sa buong bansa?)
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.)
 
P R A Y E R
(PAGSAMO)
 
WHEREFORE, plaintiff respectfully prays for judgment ordering defen-dant to pay the amount of P               , with interest at the rate of
           % per annum/per month from                                           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       .
 
 

PLAINTIFF

 

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):

                                                                       .
 
(Naghahabla)
 
 
 

           
 


 

 

 

 

 

 

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

CORPORATION

PARTNERSHIP

(Tao/Indibidwal)

(Korporasyon)

(Bakasan)

COOPERATIVE

 

SOLE PROPRIETORSHIP

(Kooperatiba)

 

(Solong Pagmamay-ari)

NATURE OF BUSINESS:

 

 

 

(Uri ng Negosyo)

 

 

 

BANKING

LENDING

 

(Bangko)

(Pagpapautang)

 

OTHERS/PLEASE INDICATE                                                       

(Iba pang uri ng negosyo)

PLAINTIFF’S  HOME ADDRESS:

 

 

 

(Pahatirang Sulat sa Bahay ng Naghahabla)

(City)                                                                                

                  

(Lungsod)

 

 

Zip Code

(Province, if applicable)                                                    

                  

(Lalawigan, kung meron)

 

 

Zip Code

Telephone No.                                

Cellphone No.                             

(Telepono Blg.)

 

(Selpon Blg.)

PLACE OF WORK:                                                                                                  

(Lugar ng Pinagtatrabahuan)

Telephone No.                                

Cellphone No.                             

(Telepono Blg.)

 

(Selpon Blg.)

NAME OF PLAINTIFF’S 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)

 

 

Zip Code

NAME OF DEFENDANT’S 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)

 

Zip Code

Telephone No.                                

Cellphone No.                             

(Telepono Blg.)

(Selpon Blg.)

PLACE OF WORK:                                                                                                  

(Lugar ng Pinagtatrabahuan)

Telephone No.                                

Cellphone No.                             

(Telepono Blg.)

(Selpon Blg.)


 

 

 

 

NAME OF DEFENDANT/S

SEX

AGE

CIVIL STATUS

(Pangalan ng Hinahabla)

(Kasarian)

(Edad)

(Katayuang Sibil)

INDIVIDUAL

CORPORATION

PARTNERSHIP

(Tao/Indibidwal)

(Korporasyon)

(Bakasan)

COOPERATIVE

 

SOLE  PROPRIETORSHIP

(Kooperatiba)

 

(Solong Pagmamay-ari)

DEFENDANT’S HOME ADDRESS:

(Pahatirang Sulat sa Bahay ng Hinahabla)

(City)                                                                                                      

(Lungsod)

 

 

Zip Code

(Province, if applicable)                                                    

                  

(Lalawigan, kung meron)

 

Zip Code

Telephone No.                                

Cellphone No.                             

(Telepono Blg.)

(Selpon Blg.)

PLACE OF WORK:                                                                                                  

(Lugar ng Pinagtatrabahuan)

Telephone No.                                

Cellphone No.                             

(Telepono Blg.)

(Selpon Blg.)

NAME OF DEFENDANT’S 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)

 

Zip Code

Telephone No.                                

Cellphone No.                             

(Telepono Blg.)

(Selpon Blg.)


In person

By phone

(Sa kanya mismo)

(Sa telepono)

In writing

Others (please specify)               

(Sa sulat)

(Iba pa) [pakisulat kung paano]


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