FORM 1-SCC

REPUBLIC OF THE PHILIPPINES

_______________________________
_______________________________
_______________________________

___________________,
Plaintiff,

vs. Civil Case No. _______________

For: ______________________
___________________,
Defendant.
x- - - - - - - - - - - - - - - - - - - - - -x

STATEMENT OF CLAIM

Plaintiff respectfully alleges:

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

NAME OF PLAINTIFF/S SEX AGE CIVIL STATUS

___________________ ______ _____ _________

INDIVIDUAL_ CORPORATION_ PARTNERSHIP_

SOLE PROPRIETORSHIP _

NAME OF REPRESENTATIVE:______________________________

ADDRESS ZIP CODE

____________________________________ _________

NAME OF DEFENDANTS//S SEX AGE CIVIL STATUS

______________________ ______ _____ _______

INDIVIDUAL___ CORPORATION___ PARTNERSHIP___

SOLE PROPRIETORSHIP _

NAME OF REPRESENTATIVE: _____________________________

ADDRESS ZIP CODE

_________________________________________ _________

2. Plaintiff is suing defendant for:

CAUSE OF ACTION
_____ Collection of Sum of Money
_____ Damages
_____ Civil aspect of Criminal Case
_____ Enforcement of Barangay Agreement

3. Plaintiff’s cause of action arose from and is evidenced by:

ACTIONABLE DOCUMENT/S AFFIDAVIT/S

_____ Promissory Note/Undertaking How many: _____

_____ Contract/Agreement
_____ Receipt
_____ Others

4. The principal obligation of defendant/s amounting to

P_____________________ became due and demandable on
______________. Interest at the rate of ______% per annum/per
month accrued on the principal sum due from such date of default.

5. Despite repeated demands by plaintiff, the latest of which

was on _______________, defendant has failed to pay the obligation.

6. _____(a) This claim has been referred to the appropriate

barangay authorities but no settlement was reached between the
parties. A Certificate to File Action was issued to the plaintiff, the
original of which is attached hereto.

_____(b) The parties are not covered by the barangay

mandatory conciliation process under the Local Government Code of
the Philippines.

Prayer

WHEREFORE, plaintiff respectfully prays for judgment to be

rendered ordering defendant to pay plaintiff the amount of
P________________________, with interest at the rate of ____%
per annum/per month, from ___________, until fully paid.

___________________________; _____20___.
PLACE WHERE FILED

PLAINTIFF