REPUBLIC OF THE PHILIPPINES

_________________________________
_________________________________

___________________________________, CIVIL CASE No. _________________

Plaintiff
For: _____________________________
-versus-

___________________________________,
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)

______________________________ ________ ________ _____________________

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)

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 ____________________________________________ ____________

(Lungsod) Zip Code

Province, if applicable ___________________________ ____________

(Lalawigan, kung meron) Zip Code

Telephone No. ___________________ Cellphone No. _________________

(Telepono Blg.) (Selpon Blg.)

PLACE OF WORK: __________________________________

(Lugar ng Pinagtatrabahuan)

Telephone No. ___________________ Cellphone No. _________________

(Telepono Blg.) (Selpon Blg.)

NAME OF PLAINTIFF’S REPRESENTATIVE:

(Pangalan ng Kinatawanan)
_______________________________________
if applicable (must be a non-lawyer)
kung meron (dapat hindi abogado)

REPRESENTATIVE’S HOME ADDRESS

City ____________________________________________ ____________

(Lungsod) Zip Code

Province, if applicable ___________________________ ____________

(Lalawigan, kung meron) Zip Code

Telephone No. ___________________ Cellphone No. _________________

(Telepono Blg.) (Selpon Blg.)

PLACE OF WORK: __________________________________

(Lugar ng Pinagtatrabahuan)

Telephone No. ___________________ Cellphone No. _________________

(Telepono Blg.) (Selpon Blg.)