Republic of the Philippines

MUNICIPAL TRIAL COURT OF BULA

5th Judicial Region
Branch_____
RUTH T. BALLEBAR,

Plaintiff,

- versus -

Civil Case No.__________

For: ___________________
___________________

MAE B. LORDAN,

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)

RUTH T. BALLEBAR
NAME OF PLAINTIFF/S

Female
SEX

30
AGE

(kasarian) (Edad)

(Pangalan ng Naghahabla)

Single
CIVIL STATUS
(katayuang Sibil)

(Put a check on any of the following)

(Pumili sa mga sumusunod at lagyan ng tsek)

__ INDIVIDUAL

___ CORPORATION

(tao/indibidual)

(korporasyon)

___ PARTNERSHIP

(bakasan)

___ COOPERATIVE

(kooperatiba)

____ SOLE PROPRIETORSHIP

(solong Pagmamay-ari)

HOME ADDRESS: CAUSIP, BULA, CAMARINES SUR

(Pahatirang Sulat sa bahay(Lungsod)

4430
Zip Code

(Province, if applicable) Camarines Sur

(Lalawigan, kung meron)

_____
Zip Code

Telephone No.____________

Cellphone No. 09994399964

(Telepono blg.)

(Selpon Blg.)
1

PLACE OF WORK___________________________________________

(Lugar ng Pinagtatrabahuhan)
MAE B. LORDAN
NAME OF DEFENDANT/S

Female
SEX

(Pangalan ng Hinahabla)

(kasarian)

__ INDIVIDUAL
(tao/indibidual)

33
AGE

(Edad)

Married
CIVIL STATUS

(Katayuang Sibil)

___ CORPORATION

(korporasyon)

___ PARTNERSHIP

(bakasan)

___ COOPERATIVE

____ SOLE PROPRIETORSHIP

(kooperatiba)

(solong Pagmamay-ari)

HOME ADDRESS: CAUSIP, BULA, CAMARINES SUR

(Pahatirang Sulat sa bahay(Lungsod)
Telephone No.____________

4430
Zip Code

Cellphone No. 09288932213

(Telepono blg.)

(Selpon Blg.)

PLACE OF WORK___________________________________________

(Lugar ng Pinagtatrabahuhan)

NAME OF REPRESENTATIVE, if applicable_________________________

(Pangalan ng Kinatawan, kung meron)

HOME ADDRESS:

__________________________

(Pahatirang Sulat sa Bahay)

Telephone No._______

_________
Zip Code

Cellphone No. _______

(Telepono blg.)

(Selpon Blg)

PLACE OF WORK___________________________________________

(Lugar ng Pinagtatrabahuhan)

Telephone No._______

Cellphone No. _______

(Telepono blg.)

(Selpon Blg)

FOR OFFICIAL USE ONLY

(Para sa Opisyal na gamit
lamang)

2. Plaintiff claims the defendant

owes Php. 60,000.00

To be accomplished by the Branch Clerk of Court

(sasagutin ng kawani ng Hukuman)

(Ang hinahabla ay umutang sa

Naghahabla ng halagang Php.
60,000.00)

(a)

1. Cause of action
__ Check
__ Promissory note
__ Contract
___ oral __ written
__ Barangay Agreement
___ Injuries
__ Accidental ___ intentional
__ Damage to Property
__ other (Please Specify
______________________

Why does the defendant owe

Plaintiff money?

(Bakit ang hinahable ay

Nagkautang ng salapi sa
Naghahabla?)

______________________________
______________________________
______________________________

(b)

2. ____Barangay conciliation required.

When did this happen?

(kailan ito nangyari?)
Date:___________________

If yes, ___Certificate to File Action

____ Compromise Agreement
Attached
___Barangay conciliation not required

(please state the reason)

(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 pagpatala 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)
(b)

How did you ask the defendant?

(Paano mo siningil ang hinahabla?)
________ In person
(sa kanya mismo)
________ In writing
(sa sulat)

(c)

4.

_____ by Phone
(Sa Telepono)
_____ others (Please specify
(iba pa) (pakisulat kung
paano

When did you do this?________________________________

__________________________________________________
(Kailan mo ginawa ito?)

What is your proof that defendant owes you money?_____________

_______________________________________________________
_______________________________________________________
_______________________________________________________
(Ano ang iyong katibayan or pruweba na ang hinahabla ay may

utang na salapi sa iyo?)

5.

Did you attach your proof to this form?

(Iyo bang inilakip and katibayan o pruweba sa Form na ito?

____________ Yes
(oo)

6.

___________ No
(hindi)

Was this claim referred to the barangay?

(Dumaan ba sa barangay ang paniningil na ito?)

_____ yes
(Oo)

_____ No
(hindi)

___ Not covered

(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?___________________________________

(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?
_______
4

(Sa court station na ito, pang ilang kaso na itong isinampa mo

sa loob ng kasalukuyang taon?______)
7.

By the filing of this action, plaintiff hereby waives any

amount in excess of Php. 100,000.00 excluding interest and costs.
(Sa pagsampa ng kasong ito, ang naghahabla ay isinusuko ang

anumang halaga na higit sa Php. 100,000.00, 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 SIXTY THOUSAND PESOS
(Php.
60,000.00) with interest at the rate of ____% per annum /per month from
_________________ until fully paid.
(Dahil dito, ang Naghahabla ay magalang na sumasamo na igawad

ang kapasiyang utusan and hinahabla na magbayad sa Naghahabla ng

halagang Php. 60,000.00, pati ang tubo na _____ bawat taon/buwan
simula _________________ hanggang ganap o lubos na mabayaran ito).
Municipality of Bula, ___ September, 2014.

RUTH T. BALLEBAR
PLAINTIFF
(Naghahabla)