FORM 1-SCC

Page (Pahina ) 1

REPUBLIC OF THE PHILIPPINES

MUNICIPAL TRIAL COURT OF PORAC
PROVINCE OF PAMPANGA

AQUINO LOAN ASSISTANCE INC.,

Plaintiff, represented by:
Analyn De Jesus

Small Claims No. ___________

- For -
Collection of Sum of Money

CATHERINE VINLUAN
& JOSIELYN REGALA (Co-maker),
Defendants,

THIS FORM IS NOT FOR SALE

AND MAY BE REPRODUCED
(Ang FORM na ito ay LIBRE at maaaring
kopyahin)
STATEMENT OF CLAIM
(HABLA NG PAGSINGIL)

1. The personal circumstances of the parties are follows:

(Ang bawat panig ay ang mga sumusunod)

AQUINO LOAN ASSISTANCE INC. ______ _______________

Name of Plaintiff/s SEX AGE CIVIL STATUS
(Pangalan ng Naghahabla) (Kasarian) (Edad) (Katayung Sibil)

(Put check on any of the following)

(Pumili sa mga sumusunod at lagyan ng tsek)

INDIVIDUAL X CORPORATION PARTNERSHIP

(Tao/Indibidual) (Korporasyon) (Bakasan)

COOPERATIVE SOLE PROPRIETORSHIP

(Kooperatiba) (Solong Pagmamay-ari)

HOME ADDRESS: (City) ____________________________________ ____________

(Pahatirang Sulat sa Bahay) (Lungsod) Zip Code

(Province, If Applicable) ______________________________ ____________

(Lalawigan, kung meron) Zip Code

Telephone No. ____887-3361 ____________ Cellphone No. _________

(Telepono Blg.) Selpon Blg.

PLACE OF WORK: Purok 2, Brgy., Lara, City of San Fernando Pampanga

(Lugar ng Pinagtatrabauhan)
FORM 1-SCC
Page (Pahina ) 2

NAME OF REPRESENTATIVE, if applicable. ANALYN DE JESUS_____________

(Pangalan ng Kinatwan, kung meron)

HOME ADDRESS: (CITY): Brgy., Lara, CSF Pamp. ________________

(Pahatirang Sulat sa Bahay) (Lungsod) Zip Code

(Province, if applicable) ______________________ _________________

Telephone No. 045-887-3361________________ Cellphone No. ___________

___CATHERINE VINLUAN___ __F___ ___________ _______________

NAME OF DEFENDANT/S SEX AGE CIVIL STATUS
(Pangalan ng Hinahabla) (Kasarian) (Edad) (Katayung Sibil)

X INDIVIDUAL CORPORATION PARTNERSHIP

(Tao/Indibidual) (Korporasyon) (Bakasan)

COOPERATIVE SOLE PROPRIETORSHIP

(Kooperatiba) (Solong Pagmamay-ari)

HOME ADDRESS: (City) Blk. 27, Lot 20, Model Community, PORac _________
(Pahatirang Sulat sa Bahay) (Lungsod) Pamp. Zip Code

(Province, If Applicable) ______________________________ ____________

(Lalawigan, kung meron) Zip Code

Telephone No. ____________________________ Cellphone No. _________

(Telepono Blg.) Selpon Blg.

PLACE OF WORK: ___________________________________________________________

(Lugar ng Pinagtatrabauhan)

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 Pinagtatrabauhan)

If more than one (1) defendant, list next defendant here|:

(Kung higit sa isa (1) ang hinahabla, ilagay ang susunod na hinahabla rito:)
FORM 1-SCC
Page (Pahina ) 3

JOSIELYN REGALA_______ ___F_____ _______________

NAME OF DEFENDANT/S SEX AGE CIVIL STATUS
(Pangalan ng Hinahabla) (Kasarian) (Edad) (Katayung Sibil)

X INDIVIDUAL CORPORATION PARTNERSHIP

(Tao/Indibidual) (Korporasyon) (Bakasan)

COOPERATIVE SOLE PROPRIETORSHIP

(Kooperatiba) (Solong Pagmamay-ari)

HOME ADDRESS: (City) Blk. 12, Lot 34 Model Comm., Porac Pamp. _________
(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 Pinagtatrabauhan)

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 Pinagtatrabauhan)

*Note: If you need more space, you can write at the back of this Form.
(*Tala: Kung kailangan mo ng karagdagang patlang, maarin mong isulat sa
likod ng Form na ito.)
FORM 1 SCC FOR OFFICIAL USE ONLY
Page ( Pahina) 4 (Para sa Opisyal na gamit lamang)
To be accomplished by the Branch Clerk of Court
(Sasagutan ng Kawani ng Hukuman)
1. Plaintiff claims the defendant 1. Cause of Action
Owes (Php30, 000.00)
(Ang Hinahabla ay umutang sa Check
Naghahabla ng halagang
(Php30, 000.00) Promissory Note

a.) Why does the defendant owe Oral Written

Plaintiff money?
(Bakit ang Hinahabla ay nagkautang Barangay Agreement
Injuries:
Ng salapi sa Naghahabla)
Accidental Intentional
________________________________
________________________________ Damage to Property

(If you need more space, please use Other )Please specify)
the back page)(Kung kailangan mo ____________________________________
ng karagdagang patlang, maaaring
gamitin ang likod ng pahinang ito.) 2. Barangay conciliation required:
If yes ______ Certificate to File Action
b.) When did this happen?
(Kailang ito nangyari? _______ Compromise Agreement Attached
Date: February 10 ,2012
_______ Barangay conciliation not required.
(Petsa) (Please state the reason)
_______________________________________________
_______________________________________________
If no specific date, give the time _______________________________________________
Period: (Kung walang tiyak na petsa,
Ibigay ang tantiyang panahon)
Date Started: ________________
(Petsang Nagsimula)
Through: ___________________
(Hanggang) _________________

c.)How did you compute the money owed to you| (Do not include court costs or
fees) PRINCIPAL + 3.465% INTEREST/MONTH = TOTAL OBLIGATION
(Paano mo kinuwenta ang salaping inutang sa iyo|) (Hindi kasama and bayad
sa pagpapatala sa hukuman.)

2. (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)
FORM 1-SCC
Page (Pahina) 5

(b) How did you ask the defendant?

(Paano mo siningil ang Hinahabla?)

X In person By Phone
(Sa kanya mismo) (Sa Telepono)

x In writing x Others (please specify) Through our collector

(Sa sulat) (Iba pa) (pakisulat kung paano)

(c) When did you do this ? ___________________________________________________

( Kailan mo ginagawa ito?)

4. What is your proof that defendant owes you money? Promissory Note
(Ano ang iyong katibayan o pruweba na ang Hinahabla ay may utang na
salapi sa iyo?)

5. Did you attached you 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 bang inilakip ang katibayan o pruweba sa barangay)

Yes No x Not covered

(Oo) (Hindi) (Hindi sakop)
State reason:
(Isulat ang dahilan)
Juridical Entity

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

executed before the barangay? _____________________________________
(Kung oo, meron ka bang Patunay sa Pagsampa ng Kaso o Kasunduan na
isinagawa sa barangay?)

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

(Sa court na ito, pang ilang kaso na itong isinampa mo sa loob ng

kasalukyang taon? ________________

7. BY THIS FILLING OF THIS ACTION, PLAINTIFF HEREBY WAIVES

ANY AMOUNT IN EXCESS OF P100, 000.00, EXCLUDING
INTEREST AND COSTS.
(Sa pagsampa ng kasong ito, ang Naghahabla ay isinusuko ang
anumang halaga na higit sa P100, 000.00, hindi kasama ng tubo at
gastos sa pagsampa ng kasong ito.)
FORM 1-SCC
PAGE (pahina) 6

PRAYER
(PAGSAMO)

WHEREFORE, plaintiff respectfully prays for judgment ordering defendant to

pay the accumulated amount of P41, 952.89 with interest at the rate of 3.465%
every month until fully paid.

(DAHIL DITO, and Naghahabla ay magalang na sumasamo na igawad ang

kapasiyahang utusan ang Hinahabla na magbayad sa Naghahabla ng
halagang P41, 952.89, pati ang tubo na 3.465% bawat taon/buwan simula
August 2014 hanggang ganap o lubos na mabayaran ito.)

____________________________
PLACE WHERE FILED
(Lugar kung saan inihain)

AQUINO LOAN ASSISTANCE INC.

PLAINTIFF
(Naghahabla)

Represented By:

ANALYN DE JESUS
 VERIFICATION AND CERTIFICATION OF NON-FORUM SHOPPING

I, ANALYN DE JESUS, of legal age, Filipino, single,

(Name) (Citizenship) (status)

and a resident of Brgy., Lara City of San Fernando, Pampanga

On oat, state:

1. That I am the authorized representative of 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 in the Supreme Court, the Court of Appeals or any other tribunal
or agency; That to the best of 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 agency, I undertake to report that fact to the Court within five
(5) days therefrom.
3. 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 hereto set my hand this 20th day of

February, 2015 at Angeles City.

ANALYN DE JESUS
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, this 20th day of February

2015 at Angeles City, affiant Analyn De Jesus who is personally known to me
to be the same person, that she is the same person who signed before me the
foregoing Verification/Certification and acknowledged that she executed the
same.

Doc. No. 128; REGINA C. GOPEZ-AGUSTIN

Page No. 27; Notary Public
Book No. XV; Until December 31, 2015
Series of 2015. PTR NO. 0543698/1-05-15/A.C
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