FORM 1-SCC

REPUBLIC OF THE PHILIPPINES

Metropolitan Trial Court
Branch II
Caloocan City

LORENA C. ALCARAZ__________,
Plaintiff,
vs. Civil Case No. 58195________
For: SMALL
CLAIMS______

RAMIL M. REYES_______________,
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)

_LORENA C. ALCARAZ_ __F __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)

INDIVIDUAL CORPORATION PARTNERSHIP

(Tao/Indibidwal) (Korporasyon) (Bakasan)

COOPERATIVE SOLE
PROPRIETORSHIP (Kooperatiba)
(Solong Pagmamay-ari)

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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) Blk 3 Lot 11 Lapu-Lapu Street, Caloocan City __1410__

(Lungsod) Zip Code

(Province, if applicable) #8 Haligi Street, Legazpi, Bicol _4500__

(Lalawigan, kung meron) Zip Code

Telephone No. 8288-16-91_____ Cellphone No. 09158765432__

(Telepono Blg.) (Selpon Blg.)

PLACE OF WORK: 18th Floor, New Call Center, Roces Ave., Makati
City
(Lugar ng Pinagtatrabahuan)

Telephone No. 8432-98-76_______ Cellphone No.

09167654321____
(Telepono Blg.) (Selpon Blg.)

NAME OF PLAINTIFF’S REPRESENTATIVE:

LORELYN C. ALCARAZ__
if applicable (must be a non-lawyer)
(Pangalan ng Kinatawan:)
(kung meron) [dapat hindi abogado]

HOME ADDRESS: (City) Blk 3 Lot 11 Lapu-Lapu Street, Caloocan 1410_

(Pahatirang Sulat sa Bahay) (Lungsod) Zip Code

(Province, if applicable) #8 Haligi Street, Legazpi, Bicol__ _4500__

(Lalawigan, kung meron) Zip Code

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FORM 1-SCC

Telephone No. 8288-16-91__ Cellphone No. 09178787190__

(Telepono Blg.) (Selpon Blg.)

PLACE OF WORK: 2nd Floor, EDJP Bldg., Quirino Ave., City of

Manila_
(Lugar ng Pinagtatrabahuan)

Telephone No. 8305-12-34__ Cellphone No. 09168901234__

(Telepono Blg.) (Selpon Blg.)

_RAMIL M. REYES___ __M _ __30__ __SINGLE___

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) Blk 2 Lot 8 Tilapia Street, Caloocan City_ __1410__

(Lungsod) Zip Code

(Province, if applicable)_N/A__________________ __N/A___

(Lalawigan, kung meron) Zip Code

Telephone No. 8288-15-98_____Cellphone No. 09281020994_____

(Telepono Blg.) (Selpon Blg.)

PLACE OF WORK: N/A________________________________________

(Lugar ng Pinagtatrabahuan)

Telephone No. N/A__________ Cellphone No. N/A__________

(Telepono Blg.) (Selpon Blg.)

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NAME OF DEFENDANT’S REPRESENTATIVE:

_N/A_______________________________
if applicable (must be a non-lawyer)
(Pangalan 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 Pinagtatrabahuan)

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__ __N/A________

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) _N/A_________________________________ __N/A___

(Lungsod) Zip Code

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(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 Pinagtatrabahuan)

Telephone No. _N/A_________ Cellphone No. _N/A____________

(Telepono Blg.) (Selpon Blg.)

NAME OF DEFENDANT’S REPRESENTATIVE:

_N/A____________________________
if applicable (must be a non-lawyer)
(Pangalan 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 Pinagtatrabahuan)

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 kailangan mo ng karagdagang patlang, maaari mong isulat
sa likod ng Form na ito.)

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FORM 1-SCC

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

P 80,000.00_______________.
(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?)
During their relationship as boyfriend-girlfriend, the defendant
asked plaintiff for the subject amount of money to start up a
business. However, three (3) months thereafter, the defendant
left the plaintiff for another woman and promised to pay the
amount before the year ends.____ (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: _10 May 2017 __________
(Petsa)

If no specific date, give the time period:

(Kung walang tiyak na petsa, ibigay ang tantiyang panahon)
Date started: _N/A_____________
(Petsa nagsimula)
Through: _N/A_______________
(Hanggang)

(c) How did you compute the money owed to you? (Do not include
court costs or fees)
_The amount is the exact amount owed by the defendant_____.
(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?)

Yes
No
(Oo) (Hindi)

If no, explain:
________________________________________________
(Kung hindi, ipaliwanag)

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(b) How did you ask the defendant?

(Paano mo siningil ang Hinahabla?)

In person By phone
(Sa kanya mismo) (Sa telepono)

In writing Others (please

specify) ______
(Sa sulat) (Iba pa) [pakisulat kung paano]

(c) When did you do this?

_December 15, 2017 until present time_______________
(Kailan mo ginawa ito?)

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

_Text messages and witness____
(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?)
Yes No
(Oo) (Hindi)

6. Was this claim referred to the barangay?

(Dumaan ba sa barangay ang paniningil na ito?)
Yes No Not Covered
(Oo) (Hindi) (Hindi sakop)

State reason:
Defendant failed to appear at the Office of the Lupong
Tagapamayapa (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: __0__
(Pang ilang kaso na itong isinampa mo sa loob ng kasalakuyang
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 P400,000.00, excluding interest and costs.
(Sa pagsampa ng kasong ito, ang Naghahabla ay isinusuko ang
anumang halaga na higit sa P400,000.00, 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 _80,000_____, with interest at the rate of
__6__% per annum/per month from _January 1, 2018___ 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_80,000____, pati ang tubo na __6__%
bawat taon/ buwan simula _January 1, 2018__ hanggang ganap o lubos
na mabayaran ito.)

_Caloocan City, Metro Manila___, June 5___, 2020_.

(Sgd.)
FOR OFFICIAL USE ONLY (Para
sa Opisyal na gamit lamang)
_LORENA C. ALCARAZ_
- To be accomplished by the Branch Clerk of Court- PLAINTIFF
(Sasagutan ng Kawani ng Hukuman) (Naghahabla)
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):
________________________________________.