REPUBLIC OF THE PHILIPPINES

THIRD JUDICIAL REGION

MUNICIPAL TRIAL COURTS IN CITIES
Cabiao, Nueva Ecija

LAND BANK OF THE PHILIPPINES,

Plaintiff,

Civil Case No. __________

For : __________________

RHODORA E. JUAN,
Defendant,

x--------------------x

STATEMENT OF CLAIM

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

LAND BANK OF THE PHILIPPINES ______ ______ ______________

Name of Plaintiff Sex Age Civil Status

(Put a check on any of the following)

[ ] INDIVIDUAL [/] CORPORATION [ ] PARTNERSHIP

[ ] COOPERATIVE [ ] SOLE PROPRIETORSHIP

OFFICE ADDRESS : (City) LBP San Isidro (NE) Branch_______

(Pahatirang Sulat sa Bahay/Lungsod) Poblacion, San Isidro____________

(Province, if applicable) Nueva Ecija______________________

(Lalawigan, kung meron)

Telephone No. _(044) 940-9982/3564 Cellphone No. 0917-559-1647

(Telepono Blg.) (Selpon Blg.)

PLACE OF WORK : _______________________________________

(Lugar ng Pinagtatrabahuhan)
NAME OF REPRESENTATIVE, if applicable NANCY A. ANGELES– Branch Head__
(Pangalan ng Kinatawan, kung meron)

OFFICE ADDRESS : (City) LandBank Building, Poblacion, San Isidro__

(Pahatirang Sulat sa Bahay/Lungsod) ___________________________________

(Province, if applicable) Nueva Ecija__________________________

(Lalawigan, kung meron)

Telephone No. _(044) 940-9982/3564 Cellphone No. ______

(Telepono Blg.) (Selpon Blg.)

_RHODORA E. JUAN__ Female 62 Widow

Name of Defendant Sex Age Civil Status
(Pangalan ng Hinahabla) (Kasarian) (edad) (Katayuang Sibil)

(Put a check on any of the following)

[/] INDIVIDUAL [ ] CORPORATION [ ] PARTNERSHIP

[ ] COOPERATIVE [ ] SOLE PROPRIETORSHIP

HOME ADDRESS : (City) 71 Kennedy St. ________

(Pahatirang Sulat sa Bahay/Lungsod) _North Greenhills, San Juan City______

(Province, if applicable) Metro Manila____________________________

(Lalawigan, kung meron)

Telephone No. ______________ Cellphone No. 0917-511-8161

(Telepono Blg.) (Selpon Blg.)

PLACE OF WORK : __MUNICIPALITY OF SAN ANTONIO, NUEVA ECIJA____

(Lugar ng Pinagtatrabahuhan)

NAME OF REPRESENTATIVE, if applicable _______________________________

(Pangalan ng Kinatawan, kung meron)

OFFICE ADDRESS : (City) Poblacion, San Antonio, Nueva Ecija

(Pahatirang Sulat sa Bahay/Lungsod)

(Province, if applicable) Nueva Ecija_____

(Lalawigan, kung meron)

Telephone No. ______________ Cellphone No. ______

(Telepono Blg.) (Selpon Blg.)
MUNICIPALITY OF SAN ANTONIO, NUEVA ECIJA_ _____________________
Name of Defendant Sex Age Civil Status
(Pangalan ng Hinahabla) (Kasarian) (edad) (Katayuang Sibil)

(Put a check on any of the following)

[ ] INDIVIDUAL [ ] CORPORATION [ ] PARTNERSHIP

[ ] COOPERATIVE [ ] SOLE PROPRIETORSHIP

OFFICE ADDRESS : (City) _________Poblacion, San Antonio_______________

(Pahatirang Sulat sa Bahay/Lungsod)

(Province, if applicable) _Nueva Ecija________________ __3108__

(Lalawigan, kung meron) Zip Code

Telephone No. ______________ Cellphone No. ______

(Telepono Blg.) (Selpon Blg.)

PLACE OF WORK : ____________________________________________

(Lugar ng Pinagtatrabahuhan)
Telephone No. ______________ Cellphone No. ______
(Telepono Blg.) (Selpon Blg.)

NAME OF REPRESENTATIVE, if applicable ____________________

(Pangalan ng Kinatawan, kung meron)

HOME ADDRESS : (City) ________________________ _______

(Pahatirang Sulat sa Bahay/Lungsod)

(Province, if applicable) ____________________ _______

(Lalawigan, kung meron)

Telephone No. ______________ Cellphone No. ______

(Telepono Blg.) (Selpon Blg.)

PLACE OF WORK : _______________________________________

(Lugar ng Pinagtatrabahuhan)
Telephone No. ______________ Cellphone No. ______
(Telepono Blg.) (Selpon Blg.)
 VILMA D. SALASAYO______ _Female ___51____ __Married__
Name of Defendant/co-maker Sex Age Civil Status
(Pangalan ng Hinahabla) (Kasarian) (edad) (Katayuang Sibil)

(Put a check on any of the following)

[/] INDIVIDUAL [ ] CORPORATION [ ] PARTNERSHIP

[ ] COOPERATIVE [ ] SOLE PROPRIETORSHIP

HOME ADDRESS : (City) __________Purok 2, Julo, San Antonio_____

(Pahatirang Sulat sa Bahay/Lungsod)

(Province, if applicable) _______Nueva Ecija____ ___3108__

(Lalawigan, kung meron) Zip Code

Telephone No. _(044) 940-3573__ Cellphone No. ______

(Telepono Blg.) (Selpon Blg.)

PLACE OF WORK : MUNICIPALITY OF SAN ANTONIO, NUEVA ECIJA____

(Lugar ng Pinagtatrabahuhan)
Telephone No. _(044) 940-3573_ Cellphone No. ______
(Telepono Blg.) (Selpon Blg.)

NAME OF REPRESENTATIVE, if applicable ____________________

(Pangalan ng Kinatawan, kung meron)

HOME ADDRESS : (City) ________________________ _______

(Pahatirang Sulat sa Bahay/Lungsod)

(Province, if applicable) ____________________ _______

(Lalawigan, kung meron)

Telephone No. ______________ Cellphone No. ______

(Telepono Blg.) (Selpon Blg.)

PLACE OF WORK : _______________________________________

(Lugar ng Pinagtatrabahuhan)
Telephone No. ______________ Cellphone No. ______
(Telepono Blg.) (Selpon Blg.)
2. Plaintiff claims the defendant owes P137,166.60 inclusive of interest and other
charges as of May 07, 2019.

(a) Why does the defendant owe plaintiff money?

(Bakit and Hinahabla ay nagkautang ng salapi sa Naghahabla?)

Defendant Rhodora E. Juan obtained a Livelihood Loan System (LLS)

from the plaintiff, LandBank of the Philippines – San Isidro NE Branch

(b) When did this happen?

(kailan ito nangyari)
Date : September 28, 2015

(c) How did you compute the money owed to you?

Principal P108,952.78
Interest 7,020.74
Penalty 21,193.08
Other Charges 0.00
------------------
TOTAL P137,166.60
=========

3. (a) Did you ask the defendant to pay you before you filed this case?

[ /] Yes [ ] No

(b) How did you ask the defendant?

(Paano mo siningil and Hinahabla)

[ / ] In person [ / ] By phone

[ / ] In writing [ / ] Others: called/coordinated with her

daughter,
Ms. Yhasmin J. Tamana, LBP employee
assigned at CCD, Head Office

(c) When did you do this ? Oct 2018, March 2019, April 2019.

4. What is your proof that Defendants owe you money?

(Ano ang inyong katibayan o pruweba na ang Hinahabla ay may
utang na salapi sayo? photocopy of (1) PN# 233-039-2150061, (2)
Livelihood Loan Application/Agreement Form, (3) Letter from
Borrower dated 10/23/2018, (4) collection letters

5. Did you attach your proof to this form?

[/] Yes [ ] No

6. Was this claim referred to the barangay?

[ ] Yes [ /] No
 If yes, do you have a Certificate to File Action or a Compromise Agreement
executed before the barangay? ______

6-A In this court station, how many small claims cases have you filed
within this calendar year prior to this present case?
_______none_________

7. By the filing of this action, plaintiff hereby waives any amount in excess of
P137,166.60 excluding interest and costs.

PRAYER

WHEREFORE, plaintiff respectfully prays for the judgement ordering defendant

to pay the amount of P137,166.60 with interest at the rate of 12% per annum and
penalty at the rate of 36% per annum from May 07, 2019 until fully paid.

(DAHIL DITO, ang naghabla ay magalang na sumasamo na igawad ang

kapasiyahang utusan and Hinahabla na magbayad sa Naghahabla ng halagang
P137,166.60 pati ang tubo na 12% bawat taon at multa na 36% bawat taon simula
May 07, 2019 hanggang ganap o lubos na mabayaran ito.)

San Isidro, Nueva Ecija _____day of ________, 2019.

PLACE WHERE FILED

(Lugar kung saan inihain)

LANDBANK OF THE PHILIPPINES

PLAINTIFF
(Naghahabla)

By:

NANCY A. ANGELES
Head, LBP San Isidro NE Branch
 CERTIFICATE OF NON-FORUM SHOPPING

Republic of the Philippines )

____________ )

I, NANCY A. ANGELES, of legal age, Filipino, with office address at Land

Bank of the Philippines, Poblacion, San Isidro, Nueva Ecija, and after being
duly sworn to in accordance with law, hereby depose and state that:

1. I am the Head of San Isidro NE Branch of Land Bank of the

Philippines situated at Poblacion, San Isidro, Nueva Ecija;

2. By the authority reposed upon me, I have caused the preparation and
of the foregoing Complaint;

3. I have thoroughly read all the allegations contained therein and that
the same are correct of my own personal knowledge;

4. To the best of my knowledge, the Land Bank of the Philippines has not
filed nor commence any other or substantially similar or identical
Complaint involving the same parties, issues, interest, property and
relief in any court, tribunal or agency and that if I should thereafter
learn that a similar action has been filed or is pending in any court,
tribunal or agency, I undertake to report to this Honorable Court, the
fact within five (5) days therefrom

NANCY A. ANGELES
Affiant

SUBSCRIBED AND SWORN to before me this ___th day

of___________ 2019, affiant exhibiting to me his Employee ID No. _____
issued by the Land Bank of the Philippines.

Doc. No. _________

Page No. _________
Book No. _________
Series of 2019