Leagl Forms

FORMS IN
SMALL CLAIMS
766
PREPARED BY: CASIM, JENELYN D.
FORM 1-SCC
REPUBLIC OF THE PHILIPPINES

NATIONAL CAPITAL JUDICIAL REGION
METROPOLITANT TRIAL COURT
QUEZON CITY, BRANCH 89
CLARK KENT, Plaintiff,
-vs- Civil Case No. 1324-

SCC
For: Small Claims
BRUCE WAYNE, 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)
CLARK KENT MALE 28 SINGLE

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)
X INDIVIDUAL CORPORATION PARTNERSHIP

(Tao/Indibidwal) (Korporasyon) (Bakasan)
COOPERATIVE SOLE PROPRIETORSHIP

(Kooperatiba) (Solong Pagmamay-ari)
NATURE OF BUSINESS:
(Uri ng Negosyo)
BANKING X LENDING
(Bangko) (Pagpapautang)
OTHERS/PLEASE INDICATE________________________
(Iba pang uri ng negosyo)
PLAINTIFF’S HOME ADDRESS:

(Pahatirang Sulat sa Bahay ng Naghahabla)
(City) QUEZON CITY 1008

(Lungsod) Zip Code
(Province, if applicable)_______________________ ________

(Lalawigan, kung meron) Zip Code
Telephone No. (02) 700-1234 Cellphone No.0990-123-

4567
(Telepono Blg.) (Selpon Blg.)
767
PLACE OF WORK: THE PLANET
(Lugar ng Pinagtatrabahuan)
Telephone No. (02) 800-1234 Cellphone No. 0900-123-

4567
NAME OF PLAINTIFF’S REPRESENTATIVE:

LOIS LANE
if applicable (must be a non-lawyer)
(Pangalan ng Kinatawan:)
(kung meron) [dapat hindi abogado]
HOME ADDRESS: (City) QUEZON CITY 1008

(Pahatirang Sulat sa Bahay) (Lungsod) Zip
Code
(Province, if applicable)_________________________
________
(Lalawigan, kung meron) Zip
Code
Telephone No. (02) 700-1234 Cellphone No.0990-765-4321

PLACE OF WORK: THE PLANET


BRUCE WAYNE MALE 30 MARRIED

NAME OF DEFENDANT/S SEX AGE CIVIL STATUS
(Pangalan ng Hinahabla) (Kasarian) (Edad) (Katayuang Sibil)
(Put a check on any of the following)

(Pumili sa mga sumusunod at lagyan ng tsek)
X INDIVIDUAL CORPORATION PARTNERSHIP

(Tao/Indibidwal) (Korporasyon) (Bakasan)
COOPERATIVE SOLE PROPRIETORSHIP

(Kooperatiba) (Solong Pagmamay-ari)
NATURE OF BUSINESS:
(Uri ng Negosyo)
X BANKING LENDING
(Bangko) (Pagpapautang)
OTHERS/PLEASE INDICATE________________________
(Iba pang uri ng negosyo)
DEFENDANT’S HOME ADDRESS:

(Pahatirang Sulat sa Bahay ng Hinahabla)
(City) QUEZON CITY 1008

(Lungsod) Zip Code
768
(Province, if applicable)_______________________ ________
(Lalawigan, kung meron) Zip Code

PLACE OF WORK: WAYNE ENTERPRISE


NAME OF PLAINTIFF’S REPRESENTATIVE:

SELINA KYLE
if applicable (must be a non-lawyer)
(Pangalan ng Kinatawan:)
(kung meron) [dapat hindi abogado]
HOME ADDRESS: (City) QUEZON CITY 1008

(Pahatirang Sulat sa Bahay) (Lungsod) Zip
Code
(Province, if applicable)_________________________
________
(Lalawigan, kung meron) Zip
Code

PLACE OF WORK: WAYNE ENTERPRISE

Telephone No. 800-1234 Cellphone No.09007654321

2. Plaintiff claims the defendant owes him/her/it: P250,000.

(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?)
To invest in stocks.
(b) When did this happen? (Kailan ito nangyari?)

Date: January 3, 2019
(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.]
From the actual loan
769
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?)
X Yes No
(Oo) (Hindi)
If no, explain:
(Kung hindi, ipaliwanag)
________________________________________________
(b) How did you ask the defendant?

(Paano mo siningil ang Hinahabla?)
In person By phone
(Sa kanya mismo) (Sa telepono)
X In writing Others (please specify) ______
(Sa sulat) (Iba pa) [pakisulat kung paano]
(c) When did you do this? February 20, 2019

(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?)
The written demand letter
5. Did you attach your proof to this form?

(Iyo bang inilakip ang katibayan o pruweba sa Form na ito?)
X Yes No
(Oo) (Hindi)
6. Was this claim referred to the barangay?

(Dumaan ba sa barangay ang paniningil na ito?)
X Yes No Not Covered

(Oo) (Hindi) (Hindi sakop)
State reason:
(Isulat ang dahilan)
_________________________________________________
If yes, do you have a Certificate to File Action or a Compromise

Agreement executed before the barangay? Yes
(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: One (1)
(Pang ilang kaso na itong isinampa mo sa loob ng
kasalakuyang taon sa korte na ito at sa buong bansa?)
770
7. By the filing of this action, plaintiff hereby waives any amount in
excess of P250,000.00, excluding interest and costs.
(Sa pagsampa ng kasong ito, ang Naghahabla ay isinusuko ang
anumang halaga na higit sa P250,000.00, 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 P 250,000, with interest at the rate of
6% per month from the time this complaint is filed until fully paid.
(DAHIL DITO, ang Naghahabla ay magalang na sumasamo na

igawad ang kapasiyahang utusan ang Hinahabla na magbayad sa
Naghahabla ng halagang P250,000, pati ang tubo na 6% buwan simula
sa araw na naisumite ang pagsingil hanggang ganap o lubos na
mabayaran ito.)
Quezon City, Philippines, 1st day of March, 2019.
FOR OFFICIAL USE ONLY (Para sa Opisyal na

gamit lamang)
CLARK KENT
- To be accomplished by the Branch Clerk of Plaintiff
Court- (Naghahabla)
(Sasagutan ng Kawani ng Hukuman)
1. Cause of action
___ Check
___ Promissory Notes
___ 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:
_______________________________
771
FORM 1-A-SCC
REPUBLIC OF THE PHILIPPINES)

CITY OF QUEZON) S.S.
VERIFICATION AND CERTIFICATIONAGAINST NON-FORUM

SHOPPING, SPLITTING A SINGLE CAUSE OF ACTION AND
MULTIPLICITY OF SUITS
I,CLARK KENT, of legal age, Filipino, Single, and a resident of 1938

Sullivan Street, Barangay Metropolis, Quezon City, on oath, state:
1. That I am the plaintiff in the above-entitled case have caused this

Statement of Claim 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 Quezon
City; 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 hereunto set my hand this 1st day

of March, 2019.
CLARK KENT
Affiant
SUBSCRIBED AND SWORN to before me this 1ST day of March,

2019, Quezon City, Philippines.
NOTARY PUBLIC
NOTARY PUBLIC
Doc. No. 2;
Page No. 4;
Book No. 1;
Series of 2019;
772
FORM 2-SCC


SCC
For: Small Claims

x- - - - - - - - - - - - - - - - - - - - - - - - - - x
SUMMONS
TO: BRUCE WAYNE

1007 Mountain Drive,
Barangay Gotham, Quezon City
GREETINGS:
You are hereby required, within ten (10) days from receipt of this
Summons, to file with this Court and serve on plaintiff, your verified
Response to the attached Statement of Claim. The form of the required
Response is attached hereto.
You are required to submit with your Response certified copies of

documents as well as affidavits of any witness to stand as your evidence
in this case. You must present the original document/s on the day of
hearing.
A motion to dismiss is prohibited and shall not be entertained. Any

ground for dismissal should be included in your Response. Likewise,
motions for bill of particulars and for extension to file pleadings,
affidavits or any other paper are prohibited.
Your failure to respond within the 10-day period AND TO APPEAR AT

THE HEARING OF THIS CASE will authorize the Court to render
judgment.
Witness my hand under the seal of this Court, this 5th day of
March, 2019, Quezon City, Philippines.
BEATRICE PORTINERI
Branch Clerk of Court
NOTE: FOR INQUIRIES, CALL TEL. # (02) 567-8901
773
FORM 3-SCC


SCC
For: Small Claims

x- - - - - - - - - - - - - - - - - - - - - - - - - - x
RESPONE
(SAGOT)
Defendant states:
(Ang Hinahabla ay nagsasaad:)
1. Defendant denies the Statement of Claim for any of the following

reasons: (Put a check in any of the following)
(Tinatanggihan ng Hinahabla ang Habla ng Pagsingil sa alinmang
sumusunod na dahilan): [Pumili sa mga sumusunod at lagyan ng tsek]
(a) X
____ Defendant does not owe plaintiff any money.
(Ang Hinahabla ay walang pagkakautang na salapi sa
Naghahabla.)
____ Defendant owes plaintiff only a portion of the amount
claimed.
(Ang utang ng Hinahabla ay bahagi lamang ng halagang
sinisingil ng Naghahabla.)
____ It is the plaintiff who owes defendant money.
(Ang Naghahabla ang siyang may utang na salapi sa
Hinahabla.)
(b) If defendant owes plaintiff only a portion of the amount claimed,

how much is this?
(Kung ang utang ng Hinahabla ay bahagi lamang ng halagang sinisingil
ng Naghahabla, magkano ito?)
P100,000
(c) If it is the plaintiff who owes defendant money, how much and
when did this happen?
(Kung ang Naghahabla ang siyang may utang na salapi sa Hinahabla,
magkano at kailan ito nangyari?)
Not applicable
If no specific date, estimate the time period:

(Kung walang tiyak na petsa, ibigay ang tantiyang panahon)
Date started _______________
(Petsa nagsimula)
Through__________________
(Hanggang)
774
(d) How did you compute the money owed you? (Do not include court
costs or fees for service.)

(Paano mo kinuwenta ang salaping pagkakautang sa iyo?) (Huwag
isama ang filing fees at bayad sa serbisyo.)
From the actual amount loaned
2. If plaintiff owes you money, did you ask plaintiff to pay you?
(Kung ang Naghahabla ay siyang may pagkakautang sa iyo, siningil mo
ba siya?)
_____ Yes _____ No
(Oo) (Hindi)
If yes, how?
(Kung oo, paano?)
____ In person ____ Others (specify) ___________

(Sa kanya mismo) (Iba pa) [ano ito?]
____ In writing
(Sa sulat)
____ By phone
(Sa telepono)
3. Do you have any proof? _____Yes _____No

(Meron ka bang anumang katibayan?) (Oo) (Hindi)
What is this proof? _____ Receipt
(Anong katibayan ito?) (Resibo)
_____ Other document
(Iba pang dokumento)
_____ Witness
(Saksi/testigo)
4. As the Statement of Claim is baseless, defendant is entitled to the

following counterclaims:
(Sa dahilang walang basehan ang Habla ng Pagsingil, ang Hinahabla ay
may karapatan sa mga ganting-habol na sumusunod)
X
____ Actual Damages for the value of the loss suffered by the filing of
the case P75,000.
(Bayad para sa aktwal na pinsalang idinulot ng pagsampa ng
kaso)
X
____ Costs of suit for the money defendant spent in filing a
countercharge against plaintiff P50,000.
(Kabayaran/Gastos sa kasong isinampa)
BRUCE WAYNE
Defendant
(Hinahabla)
775
FORM 4-SCC


SCC
For: Small Claims

x- - - - - - - - - - - - - - - - - - - - - - - - - - x
NOTICE OF HEARING
(ABISO NG PAGDINIG)
YOUR CASE IS SET for hearing before the Presiding Judge of this
Court on 27th day of March, 2019, at 10:00 AM.
(Ang inyong kaso ay diringgin ng Pinunong Hukom ng Hukumang ito sa

24th na araw ng Marso, 2019 sa ganap na alas dyes ng umaga.)
YOU MUST ATTEND THE HEARING. IF YOU CANNOT ATTEND

BECAUSE IT IS PHYSICALLY IMPOSSIBLE FOR YOU TO DO SO, YOU MAY
AUTHORIZE A REPRESENTATIVE WHO IS NOT A LAWYER TO APPEAR
FOR YOU. FOR THIS PURPOSE YOU SHOULD FILL UP FORM 5-SCC
(SPECIAL POWER OF ATTORNEY).
(KINAKAILANGAN NINYONG DUMALO SA PAGDINIG. KUNG HINDI

KAYA NG KATAWAN NINYO ANG PAGDALO NANG PERSONAL SA
PAGDINIG NG IYONG KASO, MAAARI KANG MAGPADALA NG IYONG
KINATAWAN NA HINDI ABOGADO SA PAGDINIG. SA GANITONG
LAYUNIN, PUNUAN NINYO ANG FORM 5-SCC [NATATANGING GAWAD-
KAPANGYARIHAN - SPECIAL POWER OF ATTORNEY.])
WITNESS the HON. DANTE ALIGHIERI, Presiding Judge of this

Court, this 15th day of March, 2019, at Quezon City, Philippines.
(Saksi si Kgg. Dante Alighieri, Pinunong Hukom ng Hukumang ito,

ngayong 15th na araw ng Marso 2019 dito sa Quezon City, Pilipinas.)
BEATRICE PORTINERI
(Sangay na Kawani ng Hukuman)
NOTE: FOR INQUIRIES, CALL TEL. # (02) 567-8901

(Tala: Para sa katanungan, tumawag sa Korte sa Tel. Blg. (02) 567-
8901))
776
FORM 5-SCC


SCC
For: Small Claims

x- - - - - - - - - - - - - - - - - - - - - - - - - - x
PLAINTIFF’S RETURN/MANIFESTATION
This is to certify that on March 5 and 6, 2019, the undersigned

tried to serve the Summons, Statement of Claim, together with the
Annexes and Notice of Hearing upon the defendant Bruce Wayne, but
failed and unavailing on the ground that the said defendant was not
around during the time of service.
However, on March 8, 2019, the Summons, Statement of Claim,

Annexes thereto and Notice of Hearing were served personally to Bruce
Wayne, as shown by his signature appearing at the lower portion of the
summons.
WHEREFORE, the original copy of the Summons is respectfully

returned to the Honorable Court, DULY SERVED PERSONALLY.
Quezon City, Philippines, 9th day of March, 2019.
CLARK KENT
Plaintiff
777
FORM 5-A-SCC


SCC
For: Small Claims

x- - - - - - - - - - - - - - - - - - - - - - - - - - x
PLAINTIFF’S RETURN/MANIFESTATION
This is to certify that on March 5 and 6, 2019, the undersigned

tried to serve the Summons, Statement of Claim, together with the
Annexes and Notice of Hearing upon the defendant/s name/s of
defendant/s , but failed and unavailing on the ground that the said
defendant/s was/were not around during the time of service.
However, on March 8, 2019, the Summons, Statement of Claims,

Annexes thereto and Notice of Hearing were served through Alfred
Butler, who introduced himself as a personal assistant, a person of
suitable age and discretion, residing therein, who signed at the lower
portion of the summons.
Substituted service was made after the undersigned exerted

earnest efforts to serve the Summons, together with the Statement of
Claim, Annexes thereto and the Notice of Hearing personally upon the
defendant, which proved futile.
WHEREFORE, the original copy of the Summons is respectfully

returned to the Honorable Court, DULY SERVED.
Quezon City, Philippines, 9th day of March 2019.
CLARK KENT
Plaintiff
778
FORM 6-SCC

SCC
For: Small Claims

x- - - - - - - - - - - - - - - - - - - - - - - - - - x
MOTION TO PLEAD AS INDIGENT
CLARK KENT, unto this Honorable Court, respectfully alleges that:
1. I am a resident of Quezon City;
2. My gross income and that of my immediate family does not exceed

P15,000;
3. I do not own real property with an assessed value of more than

(amount as provided in the Revised Rules of Court, as amended) as
shown by the attached Certification issued by the Office of the
City/Municipal Assessor and the City/Municipal Treasurer’s Office;
4. Due to financial constraint, I cannot afford to pay for the expenses

of a court litigation as I do not have enough funds for food, shelter and
other basic necessities;
5. Should the court render judgment in my favor, the amount of the

docket and other legal fees which I was exempted from paying shall be
a lien on the judgment, unless the court orders otherwise.
WHEREFORE, premises considered, it is respectfully prayed that I

be exempted from the payment of docket and other legal fees as
indigent pursuant to Section 21, Rule 3, in relation to Section 18, Rule
141 of the Revised Rules of Court.
Other reliefs just and equitable under the premises are likewise
prayed for.
CLARK KENT
Plaintiff
779
PREPARED BY: ARTIENDA, JULIE DIANE A.
FORM 7-SCC

Metropolitan Trial Court
National Capital Judicial Region
Branch VI, Makati City
NENITA A. DELA ROSALIE,

Plaintiff,
-versus- Civil Case No. AB- 234592

For: Sum of money
ARMANDO A. CADY,
Defendant.
x- - - - - - - - - - - - - - - - - - - - - - - - - - - - -x
MOTION FOR APPROVAL OF COMPROMISE AGREEMENT
The parties respectfully allege that:
1.Plaintiff filed this claim against defendant for:
 collection of sum of money

_____________ liquidated damages
_____________ enforcement of barangay agreement
2.The parties have come to an amicable settlement and have

executed a compromise agreement with the following terms and
conditions:
a. That the defendant admits its obligation in the above-entitled
case in the amount of two hundred thousand pesos (Php 200,000);
b. That desirous to settle the case with the plaintiff, the accused
has proposed to settle the case and pay in four equal installments with
interests and other charges.
3. The parties agree that the approval of this agreement by the

Court shall put an end to this litigation, except for purposes of execution
in case of default.
WHEREFORE, premises considered, the parties respectfully pray

that the court approve this agreement and render judgment on the basis
thereof.
Makati City, Metro Manila, Philippines, August 5, 2008.
NENITA A. DELA ROSALIE ARMANDO F. CADY
780
Plaintiff Defendant
781
FORM 8-SCC


Plaintiff,

For: Sum of money
ARMANDO A. CADY,
Defendant.
x- - - - - - - - - - - - - - - - - - - - - - - - - - - - -x
JOINT MOTION (FOR DISMISSAL)
Plaintiff and defendant, unto this Honorable Court, respectfully

allege that:
1.Plaintiff and defendant have mutually and voluntarily settled their

claim and counterclaim to the entire satisfaction of each other; and
2.The parties no longer have a cause of action against each other.
WHEREFORE, premises considered, plaintiff and defendant

respectfully pray that the plaintiff’s statement of claim and defendant’s
counterclaim incorporated in his response be dismissed.
Other reliefs just and equitable under the premises are likewise
prayed for.

Plaintiff Defendant
To the Branch Clerk of Court:
Please submit the foregoing motion for the consideration of the

Court without hearing and further argument from the parties.

Plaintiff Defendant
782
FORM 9- SCC


Plaintiff,

For: Sum of money
ARMANDO A. CADY,
Defendant.
x- - - - - - - - - - - - - - - - - - - - - - - - - - - - -x
MOTION FOR EXECUTION
Plaintiff/Defendant, unto this Honorable Court, respectfully alleges

that:
1. On December 8, 2005, a judgment was rendered by the Court,

the dispositive portion of which reads:
WHEREFORE, the judgment is rendered in favor of the plaintiff,

ordering the defendant to pay the plaintiff the amount of two
hundred thousand pesos (Php 200,000) plus interest and other
charges in accordance with the law.
2. The judgment is final, executory and unappealable.
3. The defendant has not complied with the judgment.
WHEREFORE, premises considered, it is respectfully prayed that

a writ of execution be issued to implement the judgment of the Court
dated December 8, 2005.
Makati City, Metro Manila, Philippines, December 20, 2005.
NENITA A. DELA ROSALIE

Plaintiff
NOTICE OF HEARING

Plaintiff
CHESCA F. HEROTE
783
Please be notified that the undersigned will submit the foregoing

motion for the consideration and approval of the Court on December 23,
2005 at 9 AM.

Plaintiff
784
FORM 10- SCC


Plaintiff,

For: Sum of money
ARMANDO A. CADY,
Defendant.
x- - - - - - - - - - - - - - - - - - - - - - - - - - - - -x
AGREEMENT
Having failed to resolve the matter through Judicial Dispute

Resolution, plaintiff and defendant hereby agree that judge ROBERTA S.
CORPUZ shall continue with the hearing on the instant matter and
hereby waive their right to have a different judge hear the case.

Plaintiff Defendant
785
FORM 11- SCC
(Referral to pairing judge)


Plaintiff,

For: Sum of money
ARMANDO A. CADY,
Defendant.
x- - - - - - - - - - - - - - - - - - - - - - - - - - - - -x
ORDER
In view of the failure if judicial dispute resolution and there being

no agreement from the parties to let the undersigned continue hearing
the instant case, the record of this case is transmitted to the Office of
the Clerk of Court for immediate referral by the Executive Judge to the
Pairing Judge for hearing and decision pursuant to Section 21 of the Rule
of procedure for Small Claims Cases.
SO ORDERED.
ROBERTA S. CORPUZ
Judge
786
FORM 12- SCC


Plaintiff,

For: Sum of money
ARMANDO A. CADY,
Defendant.
x- - - - - - - - - - - - - - - - - - - - - - - - - - - - -x
DECISION
(BASED ON COMPROMISE AGREEMENT)
Plaintiff filed this case against defendant for sum of money in the
amount of two hundred thousand pesos (Php 200,000).
Defendant denied plaintiff’s claim on the ground of previous

payment and set up a counterclaim for fifty thousand pesos (Php
50,000).
The parties, however, reached an amicable settlement and

submitted to the court a compromise agreement, the terms and
conditions of which are as follows:
a. That the defendant admits its obligation in the above-entitled

case in the amount of two hundred thousand pesos (Php 200,000);
b. That desirous to settle the case with the plaintiff, the accused
has proposed to settle the case and pay in four equal installments with
interests and other charges.
It appearing that the agreement is not contrary to law, morals,

good customs, public moral and public policy, and pursuant to Articles
2028 and 2037 of the Civil Code of the Philippines, the same is hereby
APPROVED and ADOPTED as the Decision of this court.
The parties are hereby ordered to faithfully comply with the terms
and conditions of the agreement.
WHEREFORE, judgment is hereby rendered approving the

Compromise Agreement and the parties are ordered to comply with the
terms and conditions, as follows:
a. That the defendant shall pay timely in four equal installments

his obligation to the plaintiff in the amount of two hundred thousand
787
pesos (Php 200,000);
b. That the payment shall be made every 5th of the month, or

pursuant to the parties’ agreement, as the parties may deem convenient
and the payment shall include interest and other charges in accordance
with the law.
c. After the completion of the payment, the obligation of the

defendant to the plaintiff shall be extinguished and in case of non-
compliance, the compromise agreement shall be declared null and void
and the plaintiff may seek immediate payment of the whole obligation.
SO ORDERED.
ROBERTA S. CORPUZ
Presiding Judge
788
Katarungang
Pambarangay
Forms
789
PREPARED BY: CALINGACION, CHARMI C.
KP FORM #1: NOTICE TO CONSTITUTE THE LUPON

Republic of the Philippines
Province of Rizal
Municipality of Angono
Barangay Dalig
OFFICE OF THE PUNONG BARANGAY
March 23, 2019
NOTICE TO CONSTITUTE THE LUPON
To All Barangay Members and All Other Persons Concerned:
In compliance with Section 1(a), Chapter 7, Title One, Book III, Local
Government Code of 1991 (Republic Act No. 7160), of the Katarungang
Pambarangay Law, notice is hereby given to constitute the Lupong
Tagapamayapa of this Barangay. The persons I am considering for
appointment are the following:
1. Joyce Santos 13. Camille Villanueva
2. Maria Clara 14. Marvin Ramos
3. John Torres 15. Noli Dela Vega
4. Janice Cruz 16. Chris Ramos
5. Evelyn Garcia 17. Jules Dimaano
6. Mia Gamboa 18. Dianne Almera
7. Angelo Guevarra 19. Angela Cruz
8. Mary Grace Mendoza 20. Marivic Rosales
9. Daniel Lopez 21. Lina Sanchez
10. Michelle Lim 22. Carla Aquino
11. Alfred Jimenez 23. Richelle Panganiban
12. Daisy Laurel 24. Aiza Reyes
25. Lovely De Castro
They have been chosen on the basis of their suitability for the task of
conciliation considering their integrity, impartiality, independence of
mind, sense of fairness and reputation for probity in view of their age,
social standing in the community, tact, patience, resourcefulness,
flexibility, open mindedness and other relevant factors. The law provides
that only those actually residing or working in the barangay who are not
expressly disqualified by law are qualified to be appointed as Lupon
members.
All persons are hereby enjoined to immediately inform me and of their
opposition to or endorsement of any or all the proposed members or
790
recommend to me other persons not included in the list but not later
than the 23rd day of March, 2019.
Juan Dela Cruz

Punong Barangay
791
KP FORM #2: APPOINTMENT LETTER

Province of Rizal
Barangay Dalig
March 23, 2019

APPOINTMENT
TO: Maria Clara
Pursuant to Chapter 7, Title One, Book III, Local Government Code
of1991 (Republic Act No. 7160), you are hereby appointed MEMBER of
the Lupong Tagapamayapa of this Barangay effective upon taking your
oath of office and until a new Lupon is constituted on the third year
following your appointment.
Juan Dela Cruz

Punong Barangay
ATTESTED:
Cherry Mendoza
Barangay Secretary
792
KP FORM #3: NOTICE OF APPOINTMENT

Province of Rizal
Barangay Dalig
March 23, 2019
NOTICE OF APPOINTMENT
Joyce Santos
John Torres
Janice Cruz
Sir/Madam:
Please be informed that you have been appointed by the Punong

Barangay as a MEMBER OF THE LUPONG TAGAPAMAYAPA, effective
upon taking your oath of office, and until a new Lupon is constituted on
the third year following your appointment. You may take your oath of
office before the Punong Barangay on March 30, 2019.
Very truly yours,
Cherry Mendoza
Barangay Secretary
793
KP FORM #4: LIST OF APPOINTED LUPON MEMBERS

Province of Rizal
Barangay Dalig
March 23, 2019
LIST OF APPOINTED LUPON MEMBERS

Listed hereunder are the duly appointed members of the Lupong
Tagapamayapa in this Barangay who shall serve as such upon taking
their oath of office and until a new Lupon is constituted on the third year
following their appointment.
1. Joyce Santos 11. Camille Villanueva
2. Maria Clara 12. Marvin Ramos
3. John Torres 13. Noli Dela Vega
4. Janice Cruz 14. Chris Ramos
5. Evelyn Garcia 15. Jules Dimaano
6. Mia Gamboa 16. Dianne Almera
7. Angelo Guevarra 17. Angela Cruz
Juan Dela Cruz

Punong Barangay
ATTESTED:
Cherry Mendoza
Barangay/Lupon Secretary
794
KP FORM #5: LUPON MEMBER OATH STATEMENT

Province of Rizal
Barangay Dalig
OATH OF OFFICE
Pursuant to Chapter 7, Title One, Book II, Local Government Code
of1991 (Republic Act No. 7160), I Evelyn Garcia, being duly qualified
and having been duly appointed MEMBER of the Lupong Tagapamayapa
of this Barangay, do hereby solemnly swear that I will faithfully and
conscientiously discharge to the best of my ability, my duties and
functions as such member and as member of the Pangkat ng
Tagapagkasundo in which I may be chosen to serve; that I will bear true
faith and allegiance to the Republic of the Philippines; that I will support
and defend its Constitution and obey the laws, legal orders and decrees
promulgated by its duly constituted authorities; and that I voluntarily
impose upon myself this obligation without any mental reservation or
purpose of evasion.
SO HELP ME GOD.
Evelyn Garcia
Member
SUBSCRIBED AND SWORN to before me this 23rd day of March, 2019.
Juan Dela Cruz

Punong Barangay
795
KP FORM #6: WITHDRAWAL OF APPOINTMENT

Province of Rizal
Barangay Dalig
OFFICE OF THE LUPONG TAGAPAMAYAPA
March 23, 2019
WITHDRAWAL OF APPOINTMENT
TO: Angelo Guevarra

After due hearing and with the concurrence of a majority of all the
Lupong Tagapamayapa members of this Barangay, your appointment as
member thereof is hereby withdrawn effective upon receipt hereof, on
the following ground/s:
[√] incapacity to discharge the duties of your office as shown by
your_repeated absences to the scheduled lupon meetings, without any
justifiable reason
[ ] unsuitability by reason of ____________
Juan Dela Cruz

Punong Barangay/Lupon Chairman
CONFORME (Signatures):
4. Alfred Jimenez 10. Richelle Panganiban
5. Daisy Laurel 11. Aiza Reyes
6. Lovely De Castro
Received this 23rd day of March, 2019.

Angelo Guevarra
Signature
796
KP FORM #7: COMPLAINANT’S FORM

Province of Rizal
Barangay Dalig
Joyce Perez Barangay Case No. 123

Complainant For: Collection of Sum of Money
— against —
Judy Ann Gener

Respondent
COMPLAINT
I hereby complain against above named respondent for violating my
rights and interests in the following manner:
1. Sometime in January 2018, respondent Judy Ann Gener
borrowed three hundred thousand pesos (P300, 000.00) from me.
Respondent promised to pay me in twelve (12) equal monthly
installments which is twenty five thousand pesos (P25, 000.00) per
month.
2. Respondent was able to pay the first and second monthly
installments. However, respondent failed to pay the subsequent
instalments on the agreed date.
3. Despite repeated demands, both oral and written, respondent
refused to pay the remaining balance.
THEREFORE, I pray that relief be granted to me in accordance with law
and/or equity:
That respondent be directed to pay me the remaining balance of
the loan, in the amount of two hundred fifty thousand pesos (P250,
000.00) plus interest.
Made this 23rd day of March, 2019.
Joyce Perez
Complainant
797
Received and filed this 23rd day of March, 2019.
Juan Dela Cruz
798
KP FORM #8: NOTICE OF HEARING

Province of Rizal
Barangay Dalig
NOTICE OF HEARING
(MEDIATION PROCEEDINGS)
TO: Joyce Perez
Complainant
You are hereby required to appear before me on the 30th day of March,
2019 at 10:00 o’clock in the morning for the hearing of your complaint.
This 23rd day of March, 2019.
Juan Dela Cruz

Notified this 23rd day of March, 2019.
Complainant
Joyce Perez
799
KP FORM #9: SUMMON FOR THE RESPONDENT

Province of Rizal
Barangay Dalig

Complainant For: Collection of sum of money
— against —
Judy Ann Gener
Respondent
SUMMONS
TO: Judy Ann Gener
Respondent
You are hereby summoned to appear before me in person, together with

your witnesses, on the 30th day of March, 2019 at 10:00 o’clock in the
morning, then and there to answer to a complaint made before me, copy
of which is attached hereto, for mediation/conciliation of your dispute
with complainant. You are hereby warned that if you refuse or willfully
fail to appear in obedience to this summons, you may be barred from
filing any counterclaim arising from said complaint.
FAIL NOT or else face punishment as for contempt of court.
Juan Dela Cruz

Punong Barangay/Pangkat Chairman
Back page
OFFICER’S RETURN
I served this summons upon respondent Judy Ann Gener on the 25th day
of March, 2019 by: handing to her said summons in person.
800
Sonny Bartolome
Officer
Received by Respondent
Judy Ann Gener March 25, 2019
Signature Date
801
KP FORM #10: NOTICE FOR CONSTITUTION OF PANGKAT

Province of Rizal
Barangay Dalig
NOTICE FOR CONSTITUTION OF PANGKAT
TO: Joyce Perez Judy Ann Gener

Complainant Respondent
You are hereby required to appear before me on the 25th day of April,
2019, at 8:00 o’clock in the morning for the constitution of the Pangkat
ng Tagapagkasundo which shall conciliate your dispute. Should you fail
to agree on the Pangkat membership or to appear on the aforesaid date
for the constitution of the Pangkat, I shall determine the membership
thereof by drawing lots.
This 15th day of April, 2019.
Juan Dela Cruz

Punong Barangay
Notified this 15th day of April, 2019.

802
KP FORM #11: NOTICE TO CHOSEN PANGKAT MEMBER

Province of Rizal
Barangay Dalig

— against —
Judy Ann Gener

Respondent
NOTICE TO CHOSEN PANGKAT MEMBER
March 23, 2019

TO: Aiza Reyes
Notice is hereby given that you have been chosen member of the
Pangkat ng Tagapagkasundo amicably conciliate the dispute between
the par in the above-entitled case.
Juan Dela Cruz

Punong Barangay/Lupon Secretary
Received this 23rd day of March, 2019.
Aiza Reyes
Pangkat Member
803
KP FORM #12: NOTICE OF HEARING (CONCILIATION
PROCEEDINGS)

Province of Rizal
Barangay Dalig

NOTICE OF HEARING (CONCILIATION PROCEEDINGS)
You are hereby required to appear before the Pangkat on the 30 th day
of March, 2019, at 8:00 o’clock for a hearing of the above-entitled case.
Juan Dela Cruz

Pangkat Chairman
Joyce Perez Judy Ann Gener
804
KP FORM #13: SUBPOENA LETTER

Province of Rizal
Barangay Dalig
Barangay Case No.123

Joyce Perez For: Collection of Sum of Money
Complainant
— against —
Judy Ann Gener

Respondent
SUBPOENA
TO: Luis Samson Maria Losano

Witnesses
You are hereby commanded to appear before me on the 25th day of
March, 2019, at 8:00 o’clock, then and there to testify in the hearing of
the above-captioned case.
Juan Dela Cruz

805
KP FORM #14: AGREEMENT FOR ARBITRATION

Province of Rizal
Barangay Dalig
Barangay Case No. 123

Complainant
— against —
Judy Ann Gener

Respondent
AGREEMENT FOR ARBITRATION

We hereby agree to submit our dispute for arbitration to the Punong
Barangay/Pangkat ng Tagapagkasundo and bind ourselves to comply
with the award that maybe rendered thereon. We have made this
agreement freely with a full understanding of its nature and
consequences.
Entered into this 23rd day of March, 2019.
ATTESTATION
I hereby certify that the foregoing Agreement for Arbitration was
entered into by the parties freely and voluntarily, after I had explained
to them the nature and the consequences of such agreement.
Juan Dela Cruz

806
KP FORM #15: ARBITRATION AWARD

Province of Rizal
Barangay Dalig

Complainant
— against —
Judy Ann Gener

Respondent
ARBITRATION AWARD
After hearing the testimonies given and careful examination of the
evidence presented in this case, award is hereby made that;
The respondent is ordered to pay the remaining balance of the loan with
6% interest, to be paid within 30 days from the receipt of this award.
Made this 23rd day of March, 2019 at Angono, Rizal.

Juan Dela Cuz
Jason Santos
Member
Melvin Martin
Member
ATTESTED:
Cherry Mendoza
Punong Barangay/Lupon Secretary
807
KP FORM # 16: AMICABLE SETTLEMENT

Province of Rizal
Barangay Dalig

Complainant
— against —
Judy Ann Gener

Respondent
AMICABLE SETTLEMENT
We, complainant and respondent in the above-captioned case, do
hereby agree to settle our dispute as follows:
1. Respondent will pay the remaining balance of the loan with no
interest.
2. Respondent will pay the loan balance by monthly installments,
in the amount of P25, 000.00, starting April 2019.
and bind ourselves to comply honestly and faithfully with the above
terms of settlement.
Entered into this 23rd day of March, 2019.
ATTESTATION
I hereby certify that the foregoing amicable settlement was entered into
by the parties freely and voluntarily, after I had explained to them the
nature and consequence of such settlement.
Juan Dela Cruz
808
KP FORM #17: REPUDIATION

Province of Rizal
Barangay Dalig

Complainant
— against —
Judy Ann Gener

Respondent
REPUDIATION
I hereby repudiate the settlement agreement on the ground that my

consent was vitiated by fraud. The respondent misrepresented that she
is willing to comply with the settlement and that she has the means to
pay, in order to avoid litigation.
SUBSCRIBED AND SWORN TO before me this 23rd day of March, 2019

at Angono, Rizal.
Juan Dela Cuz

Punong Barangay/Pangkat Chairman/Member
809
KPFORM #18: NOTICE OF HEARING FOR COMPLAINANT

Province of Rizal
Barangay Dalig

Complainant
— against —
Judy Ann Gener

Respondent
NOTICE OF HEARING
(RE: FAILURE TO APPEAR)

TO: Joyce Perez
Complainant
You are hereby required to appear before me/the Pangkat on the 28th
day of March, 2019, at 8:00 o’clock in the morning/afternoon to explain
why you failed to appear for mediation/conciliation scheduled on March
15, 2019, and why your complaint should not be dismissed, a certificate
to bar the filing of your action on court/government office should not be
issued, and contempt proceedings should not be initiated in court for
willful failure or refusal to appear before the Punong Barangay/Pangkat
ng Tagapagkasundo.
Juan Dela Cruz

Notified this 23rd day of March, 2019
Complainant
Joyce Perez
Respondent
Judy Ann Gener
810
KP FORM #19: NOTICE OF HEARING FOR RESPONDENT

Province of Rizal
Barangay Dalig

— against —
Judy Ann Gener

Respondent
NOTICE OF HEARING
(RE: FAILURE TO APPEAR)
TO: Judy Ann Gener

Respondent
You are hereby required to appear me/the Pangkat on the 28 th day of

March, 2019, at 8:00 o’clock in the morning/afternoon to explain why
you failed to appear for mediation/conciliation scheduled on March 15,
2019 and why your counterclaim (if any) arising from the complaint
should not be dismissed, a certificate to bar the filing of said
counterclaim in court/government office should not be issued, and
contempt proceedings should not be initiated in court for willful failure
or refusal to appear before the Punong Barangay/Pangkat ng
Tagapagkasundo. This 23rd day of March, 2019.
Juan Dela Cruz

Respondent Complainant
811
KP FORM #20: CERTIFICATION TO FILE ACTION (FROM LUPON
SECRETARY)

Province of Rizal
Barangay Dalig

— against —
Judy Ann Perez

Respondent/s
CERTIFICATION TO FILE ACTION
This is to certify that:
1. There has been a personal confrontation between the parties before

the Punong Barangay/Pangkat ng Tagapagkasundo;
2. A settlement was reached;
3. The settlement has been repudiated in a statement sworn to before
the Punong Barangay by Joyce Perez on ground of fraud; and
4. Therefore, the corresponding complaint for the dispute may now be
filed in court/government office.
Cherry Mendoza
Lupon Secretary
Attested:
Juan Dela Cruz
Lupon Chairman
812
KP FORM #21: CERTIFICATION TO FILE ACTION (FROM
PANGKAT SECRETARY)

Province of Rizal
Barangay Dalig

Complainant
— against —
Judy Ann Gener

Respondent
1. There has been a personal confrontation between the parties before

the Punong Barangay but mediation failed;
2. The Pangkat ng Tagapagkasundo was constituted but the personal

confrontation before the Pangkat likewise did not result into a
settlement; and

Cherry Mendoza
Pangkat Secretary
Attested by:
Juan Dela Cruz

Pangkat Chairman
813
KP FORM #22: CERTIFICATION TO FILE ACTION

Province of Rizal
Barangay Dalig

— against —
Judy Ann Gener

Respondent
1. There was a personal confrontation between the parties before the

Punong Barangay but mediation failed;
2. The Punong Barangay set the meeting of the parties for the
constitution of the Pangkat;
3. The respondent willfully failed or refused to appear without justifiable

reason at the conciliation proceedings before the Pangkat; and

Cherry Mendoza
Pangkat Secretary
Attested by:
Juan Dela Cruz

Pangkat Chairman
814
KP FORM #23: CERTIFICATION TO BAR ACTION

Province of Rizal
Barangay Dalig

— against —
Judy Ann Gener

Respondent
CERTIFICATION TO BAR ACTION
This is to certify that the above-captioned case was dismissed pursuant

to the Order dated March 15, 2019, for complainant Joyce Perez and
Judy Ann Gener willful failure or refusal to appear for hearing before the
Punong Barangay/Pangkat ng Tagapagkasundo and therefore
complainant is barred from filing an action in court/government office.
Cherry Mendoza
Lupon Secretary/Pangkat Secretary
Attested:
Juan Dela Cruz

Lupon Chairman/Pangkat Chairman
815
KP FORM #24: CERTIFICATION TO BAR COUNTERCLAIM

Province of Rizal
Barangay Dalig

Complainant
— against —
Judy Ann Gener

Respondent
CERTIFICATION TO BAR COUNTERCLAIM
This is to certify that after prior notice and hearing, the respondent Judy
Ann Gener has been found to have willfully failed or refused to appear
without justifiable reason before the Punong Barangay/Pangkat ng
Tagapagkasundo and therefore respondent is barred from filing her
counterclaim (if any) arising from the complaint in court/government
office.
Cherry Mendoza
Lupon Secretary/Pangkat Secretary
Attested:
Juan Dela Cruz

Lupon Chairman/Pangkat Chairman
816
KP FORM #25: MOTION FOR EXECUTION

Province of Rizal
Barangay Dalig

Complainant
— against —
Judy Ann Gener

Respondent
MOTION FOR EXECUTION
Complainant state as follows:
1. On March 23, 2019, the parties in this case signed an amicable

settlement/received the arbitration award rendered by the
Lupon/Chairman/Pangkat ng Tagapagkasundo;
2. The period of ten (10) days from the above-stated date has expired
without any of the parties filing a sworn statement of repudiation of the
settlement before the Lupon Chairman a petition for nullification of the
arbitration award in court; and
3. The amicable settlement/arbitration award is now final and executory.
WHEREFORE, Complainant request that the corresponding writ of

execution be issued by the Lupon Chairman in this case.
April 5, 2019
Joyce Perez
Complainant
817
KP FORM #26: NOTICE OF HEARING (RE: MOTION FOR
EXECUTION)

Province of Rizal
Barangay Dalig

— against —
Judy Ann Gener

Respondent
NOTICE OF HEARING
(RE: MOTION FOR EXECUTION)

You are hereby required to appear before me on 28th day of March 2019
at 8:00 o’clock in the morning/ for the hearing of the motion for
execution, copy of which is attached hereto, filed by Joyce Pere on March
5, 2019.
Juan Dela Cruz

Notified this 23rd day of March 2019.
Joyce Perez Judy Anne Gener

818
KP FORM #27: NOTICE OF EXECUTION

Province of Rizal
Barangay Dalig

Complainant
— against —
Judy Ann Gener

Respondent
NOTICE OF EXECUTION
WHEREAS, on March 30, 2019, an amicable settlement was signed by

the parties in the above-entitled case was rendered by the Punong
Barangay/Pangkat ng Tagapagkasundo;
WHEREAS, the terms and conditions of the settlement, the dispositive

portion of the award. read:
1. Respondent will pay the remaining balance of the loan with no

interest.
2. Respondent will pay the loan balance by monthly installments,
in the amount of P25, 000.00, starting April 2019.
The said settlement/award is now final and executory;
WHEREAS, the party obliged Judy Ann Gener has not complied
voluntarily with the aforestated amicable settlement, within the period
of five (5) days from the date of hearing on the motion for execution;
NOW, THEREFORE, in behalf of the Lupong Tagapamayapa and by virtue

of the powers vested in me and the Lupon by the Katarungang
Pambarangay Law and Rules, I shall cause to be realized from the goods
and personal property of Judy Ann Gener the sum of two hundred fifty
thousand pesos (P250, 000.00) upon in the said amicable settlement,
unless voluntary compliance of said settlement shall have been made
upon receipt hereof.
Signed this 23rd day of March, 2019.
Juan Dela Cruz

Punong Barangay
Copy furnished:
819
KP FORM #28: MONTHLY TRANSMITTAL OF FINAL REPORTS

Province of Rizal
Barangay Dalig

OFFICE OF THE BARANGAY CAPTAIN
March 23, 2019
MONTHLY TRANSMITTAL OF FINAL REPORTS
To: Hon. Isagani Ibarra

(Judge, Municipality of Angono)
Enclosed herewith are the final reports of settlement of disputes

and arbitration awards made by the Barangay Captain/ Pangkat
Tagapagkasundo in the following cases:
Barangay Case No. TITLE

(Complainant, et al. vs. Respondent, et al)
1 Nancy Burgos v. Pedro Pentinio

2 Marites Ramos v. Salie Santos
3 Sonny Reyes, et al. v. Francis Martin
4 Tristan Lopez v. Richard Dantes
5 Julio Diaz v. Willie Dy
6 Rose Jimenez v. Charlie Rosario
7 Juan Dela Vega v. Maria Gomez
8 Lucy Briones v. Xander Castro
9 Kurt Lapuz v. John Torres
10 Joyce Perez v. Judy Ann Gener
Ronald Lozano
(Clerk of Court)
820
Forms in
Summary Procedure
(Criminal Cases)
821
PREPARED BY: ARTIENDA, JULIE DIANE A.
CRIMINAL CASE UNDER SUMMARY PROCEDURE: COMPLAINT

AFFIDAVIT FOR VIOLATION OF BP 22

PEOPLE OF THE PHILIPPINES,

Plaintiff,
-versus- Criminal Case No. AB- 234580
TOMAS A. COROMULLIAYOSH,
Defendant.
COMPLAINT AFFIDAVIT FOR VIOLATION OF B.P BLG. 22

I, Ricardo A. Dalisay, of legal age and a resident of 22 Sampaguita
St. Brgy. Bagong Bato, Quezon City, after being sworn in accordance
with law depose and say that:
1. On August 3, 2003, the respondent borrowed the amount of
21,000 from me, obliging himself to pay on or before November 5, 2003.
2. As payment of the said loan obligation, he issued to me a post-
dated check. A copy of said check is attached as Annex “A”.
3. Upon presentment for clearing or collection, the check was
dishonored by the drawee bank for the reason “Account Closed”. The
bank debit advice to that effect is hereto attached as Annex “B”.
4. Notice of Dishonor and Demand for payment were made upon
respondent, but the latter simply ignored them. A copy of the notice is
here attached to as Annex “C”.
5. I am executing this sworn statement for the purpose of
charging the respondent with having violated BP. Blg. 22.
Makati City, December 5, 2003.
RICARDO A. DALISAY
Complainant
SUBSCRIBED AND SWORN to before me, this 5th day of

December, 2003 by RICARDO A. DALISAY who exhibited to me
his Community Tax Certificate No. 88888 issued at Makati City,
Philippines on January 3, 2003.
822
NOTARY PUBLIC
Doc. No. 2;
Page No. 3;
Book No. V;
Series No. 2008.
I hereby certify that I have personally examined the affiant and

that I am convinced that he voluntarily executed the foregoing
affidavit and that he understand the contents thereof.
PROSECUTOR THEA MARIE A. CRISOLOGO

Assistant City Prosecutor
823
CRIMINAL CASE UNDER SUMMARY PROCEDURE: INFORMATION
FOR VIOLATION OF BP 22


Plaintiff,
TOMAS A. COROMULLIAYOSH,
Defendant.
INFORMATION
The undersigned Assistant City Prosecutor, upon sworn complaint
originally filed by the offended party, accuses Tomas A. Coromulliayosh
for having violated B.P Blg. 22, committed as follows:
That on or about or during the period comprised between October
and November 2003 in the City of Makati, province of Metro Manila,
Philippines, within the jurisdiction of this court, the said accused, did
then and there draw and issue Check No. 88889909 dated October 30,
2003 in favor of Ricardo A. Dalisay purportedly in payment of a loan,
which upon presentment for clearing or collection was dishonored by the
drawee bank for the reason “Account Closed” and which check the
accused failed to replace with cash within five day from notice of
disclosure.
Contrary to law.
Quezon City, December 23, 2003.

Witnesses:
Harvey A. Alito
Migel S. Alibaba
824
CRIMINAL CASE UNDER SUMMARY PROCEDURE: COMPLAINT
FOR VIOLATION OF METROPOLITAN ORDINANCE


Plaintiff,
TOTO S. SAN SEBASTIANA,

Defendant.
COMPLAINT
The undersigned accuses TOTO S. SAN SEBASTIANA of a violation
of Metropolitan Ordinance No. 9898989 of the Municipality of Makati,
committed as follows:
That on or about April 3, 2004 in the Municipality of Makati,
province of Metro Manila, Philippines, within the jurisdiction of this court,
the aforesaid accused, did then and there willfully and unlawfully sell
pork outside the public market; that is, in the sitio known as Bagong
Buhay of said Municipality.
Act was committed in violation of the aforesaid Metropolitan
ordinance.
Makati City, Metro Manila, Philippines, April 28, 2004.
NICANDRO S. TAWITAWI
Chief of Police
Witnesses:
Harvey A. Alito
Migel S. Alibaba
APPROVED: LUCY TOMAS-BINAISH

Metropolitan Mayor
825
CRIMINAL CASE UNDER SUMMARY PROCEDURE: INFORMATION
FOR DAMAGE TO PROPERTY THROUGH RECKLESS IMPRUDENCE
AMOUNTING TO NOT MORE THAN 10,000


Plaintiff,
TOTO S. SAN SEBASTIANA,

Defendant.
INFORMATION
The undersigned accuses TOTO S. SAN SEBASTIANA of damage
to property through reckless imprudence, committed as follows:
That on or about December 8, 2005, in the Municipality of Makati,
province of Metro Manila, Philippines, within the jurisdiction of this court,
the said accused, being then the chauffeur of automobile with license
plate no. 234323, willfully and unlawfully managed and operated the
same while passing along Buendia Road in a negligent, careless and
imprudent manner, without due regard to the traffic laws, regulations
and ordinances of Makati City and without taking the necessary
precaution to prevent injury to persons and damage to property, causing
by such negligence, carelessness and imprudence the said automobile
to strike and collide with a jeep, with plate no. 95849 belonging to
CHRISTIAN A. MABAIT thereby causing damage to said public vehicle
amounting to 5,000, Philippine currency.
Contrary to law.

Witnesses:
Harvey A. Alito
Migel S. Alibaba
826

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FORMS IN

REPUBLIC OF THE PHILIPPINES

CLARK KENT, Plaintiff,

-vs- Civil Case No. 1324-

BRUCE WAYNE, Defendant.

1. The personal circumstances of the parties are as follows:

CLARK KENT MALE 28 SINGLE

(Put a check on any of the following)

X INDIVIDUAL CORPORATION PARTNERSHIP

COOPERATIVE SOLE PROPRIETORSHIP

PLAINTIFF’S HOME ADDRESS:

(City) QUEZON CITY 1008

(Province, if applicable)_______________________ ________

Telephone No. (02) 700-1234 Cellphone No.0990-123-

Telephone No. (02) 800-1234 Cellphone No. 0900-123-

NAME OF PLAINTIFF’S REPRESENTATIVE:

HOME ADDRESS: (City) QUEZON CITY 1008

Telephone No. (02) 700-1234 Cellphone No.0990-765-4321

PLACE OF WORK: THE PLANET

Telephone No. (02) 800-1234 Cellphone No.0900-765-4321

BRUCE WAYNE MALE 30 MARRIED

(Put a check on any of the following)

X INDIVIDUAL CORPORATION PARTNERSHIP

COOPERATIVE SOLE PROPRIETORSHIP

DEFENDANT’S HOME ADDRESS:

(City) QUEZON CITY 1008

Telephone No. (02) 900-1234 Cellphone No.0912-345-6789

PLACE OF WORK: WAYNE ENTERPRISE

Telephone No. (02) 900-1234 Cellphone No.0998-765-4321

NAME OF PLAINTIFF’S REPRESENTATIVE:

HOME ADDRESS: (City) QUEZON CITY 1008

Telephone No. (02) 612-3456 Cellphone No.0977-665-5443

PLACE OF WORK: WAYNE ENTERPRISE

Telephone No. 800-1234 Cellphone No.09007654321

2. Plaintiff claims the defendant owes him/her/it: P250,000.

(a) Why does the defendant owe plaintiff money?

(b) When did this happen? (Kailan ito nangyari?)

If no specific date, give the time period:

(b) How did you ask the defendant?

(c) When did you do this? February 20, 2019

4. What is your proof that defendant owes you money?

5. Did you attach your proof to this form?

6. Was this claim referred to the barangay?

X Yes No Not Covered

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

WHEREFORE, plaintiff respectfully prays for judgment ordering

(DAHIL DITO, ang Naghahabla ay magalang na sumasamo na

Quezon City, Philippines, 1st day of March, 2019.

FOR OFFICIAL USE ONLY (Para sa Opisyal na

2. ___ Barangay conciliation required.

REPUBLIC OF THE PHILIPPINES)

VERIFICATION AND CERTIFICATIONAGAINST NON-FORUM

I,CLARK KENT, of legal age, Filipino, Single, and a resident of 1938

1. That I am the plaintiff in the above-entitled case have caused this

2. That I have not commenced any action or proceeding involving

4. That I knowingly and voluntarily waive and forego the institution

IN WITNESS WHEREOF, I have hereunto set my hand this 1st day

SUBSCRIBED AND SWORN to before me this 1ST day of March,

REPUBLIC OF THE PHILIPPINES

CLARK KENT, Plaintiff,

-vs- Civil Case No. 1324-

BRUCE WAYNE, Defendant.

TO: BRUCE WAYNE

You are required to submit with your Response certified copies of

(Province, if applicable)_______________

In person Others (specify) _______

3. Do you have any proof? _Yes _No